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Physical activity lowers mortality and heart disease risks
Comment
Physical activity lowers mortality and heart disease risks Non-communicable diseases pose a huge health5 and economic burden to lower-middle-income countries, low-income countries, and individuals. These diseases cost China an estimated US$27·8 trillion and India $6·2 trillion (from 2012 to 2030), with cardiovascular disease being one of the most costly.6 Poor people in these countries are the worst affected, and with little access to preventive care they are also least likely to get evidence-based treatment and they have higher 30-day mortality outcomes.7 Cardiovascular disease is known to have devastating effects on individuals and families. In low-income and lower-middle-income countries, cardiovascular disease can push people to below the poverty line. In a study of the personal economic effect of cardiovascular disease hospitalisation in four lower-middle-income countries (India, China, Argentina, and Tanzania), catastrophic health spending likely to lead to impoverishment was present in more than 50% of the respondents in three of the countries (China, India, and Tanzania). Most participants also reported a decrease in self-reported health, loss of job, and decreases in family income and productivity. Distress financing and lost income were common, and resulted in people taking loans, selling assets, and consequently plunging into debt.8 Physical activity also lowers the risk of diabetes and cancers, lowers air pollution, and is good for the environment. Measures that boost physical activity in populations will also help achieve eight of the
www.thelancet.com Published online September 21, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32104-9
Published Online September 21, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)32104-9 See Online/Articles http://dx.doi.org/10.1016/ S0140-6736(17)31634-3
Danish Siddiqui/Reuters
In The Lancet, Scott A Lear and colleagues1 report results from a large cohort of 130 843 participants from 17 countries (including four low-income countries and seven middle-income countries) investigating the beneficial dose-dependent associations of all forms of physical activity with reduced mortality and cardiovascular disease risks.1 This is another confirmation that physical activity has definite and dose-dependent benefits for lowering risks of all-cause mortality and cardiovascular disease (heart attacks, stroke, and heart failure). What this Article contributes is evidence from low-income countries and middle-income countries on the benefits of physical activity from daily recreational and non-recreational activities, which includes physical activity at work, during household activities, and for transport. We already have robust evidence on the health benefits of physical activity,2,3 based primarily on studies from high-income countries. This study indicates that all types of physical activity are equally effective, and the protection accrued from physical activity in the current study that includes low-income countries and middleincome countries seems to be of similar magnitude. For example, in the context of benefits in lowering mortality, those meeting physical activity recommendations of at least 150 min of moderate activity per week had a 28% lower hazard ratio (HR) of mortality1 compared with a 22% lower risk ratio (RR) reported by Lee and colleagues.2 Similarly, Lear and colleagues1 report a 20% lower risk (HR) of cardiovascular disease (which includes coronary heart disease, stroke, and heart failure), while and Lee2 and Sattelmair3 and their colleagues reported a 14% lower risk (RR) of coronary heart disease. Additionally, the curvilinear shape of the dosedependent relation between physical activity and mortality and disease rates in Lear and colleagues’ study mirrors what has been observed in high-income countries,4 and provides an encouraging message: the largest risk reductions are seen between participants not meeting current physical activity recommendations and those meeting these recommendations—the equivalent of 150 min of moderate activity per week, from all forms of physical activity. For those willing to do more, additional risk reductions occurred at 150–750 min per week, and more than 750 min of activity per week, beyond which, risk reductions started to plateau.
1
Comment
UN Sustainable Developmental Goals.9 It is rare to find an intervention that has such powerful and far-reaching benefits across so many spheres. Creating a physical, social, and political environment where physical activity in daily living is desirable, accessible, and safe should be a developmental imperative; a planning, economic, social, and equity imperative; and a public health imperative. Parallel to pedestrian pavements, we need additional active transport roads for the many different modes of active transport along with cycling. It is important to note that the environment, dynamics, and context of lower-middle-income countries and low-income countries are different and pose many challenges, including rapid urbanisation, large populations, many different active and motorised transports on the roads, migration, wide socioeconomic disparities, rampant encroachment, air pollution, and high ambient temperatures, which can lead to heat exhaustion, dehydration, and decreased productivity, with potential for heat strokes. Trees on active transport roads, pavements, and lanes along with green spaces lower the ambient air temperature, help encourage breeze, lower the extreme heat, mitigate noise pollution, lower air pollution, and have a co-benefit of conserving fossil fuels by decreasing and avoiding artificial air cooling or conditioning and by promoting and making walking and cycling more comfortable. Trees and greenery in and around homes, workplaces, and schools are also known to have many health benefits, such as lowering risks of mortality, prostate cancer, and depression, and leading to better cognitive development and refraction.10,11 Open green spaces within 0·5 km radius12 of homes, workplaces, and educational institutes, encouraging participation in sports and local dances, wide pedestrian pavements, and limitations on the width of roads are some measures requiring urgent attention. In their quest for rapid development, governments in many low-income and lower-middle-income countries con centrate on construction and widening of roads for motorised transport at the cost of trees, green spaces, pedestrians, and other active transport priorities. However, a measure of development of a country is
2
how well we treat pedestrians and those using active transport. Promotion of physical activity, active transport, and active living by means of interventions contextualised to culture and context will have powerful and longlasting effects on population health and developmental sustainability. *Shifalika Goenka, I-Min Lee Indian Institute of Public Health, Public Health Foundation of India, and Center for Chronic Disease Control, New Delhi, India (SG); and Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA (I-ML) [email protected] We declare no competing interests. SG is supported by the Bernard Lown Scholars in Cardiovascular Health Program, Harvard T H Chan School of Public Health, and a Wellcome Trust (grant 096735/B/11/Z). 1
Lear SA, Hu W, Rangarajan S, et al. The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 highincome, middle-income, and low-income countries: the PURE study. Lancet 2017; published online Sept 21. http://dx.doi.org/10.1016/ S0140-6736(17)31634-3. 2 Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380: 219–29. 3 Sattelmair J, Pertman J, Ding EL, Kohl HW, III, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation 2011; 124: 789–95. 4 Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med 2015; 175: 959–67. 5 Roth GA, Johnson C, Abajobir A, et al. Global, regional, and national burden of cardiovascular diseases for 10 Causes, 1990 to 2015. J Am Coll Cardiol 2017; 70: 1–25. 6 Bloom DE, Cafiero ET, McGovern ME, et al. The macroeconomic impact of non-communicable diseases in China and India: estimates, projections, and comparisons. August, 2013. National Bureau of Economic Research. NBER working paper series, working paper 19335. http://pure.qub.ac.uk/portal/ files/17033974/McGovern_Economic_Impact_NCDs_JOEA_14.pdf (accessed July 26, 2017). 7 Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet 2008; 371: 1435–42. 8 Huffman MD, Rao KD, Pichon-Riviere A, et al. A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries. PLoS One 2011; 6: e20821. 9 The Bangkok Declaration on Physical Activity for Global Health and Sustainable Development. 2016. http://www.ispah.org/resources (accessed July 26, 2017). 10 James P, Hart JE, Banay RF, Laden F. Exposure to greenness and mortality in a nationwide prospective cohort study of women. Environ Health Perspect 2016; 124: 1344–52. 11 Demoury C, Thierry B, Richard H, Sigler B, Kestens Y, Parent ME. Residential greenness and risk of prostate cancer: a case-control study in Montreal, Canada. Environ Int 2017; 1998: 129–36. 12 Sallis JF, Cerin E, Conway TL, et al. Physical activity in relation to urban environments in 14 cities worldwide: a cross-sectional study. Lancet 2016 387: 2207–17.
www.thelancet.com Published online September 21, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32104-9
Physical activity lowers mortality and heart disease risks Non-communicable diseases pose a huge health5 and economic burden to lower-middle-income countries, low-income countries, and individuals. These diseases cost China an estimated US$27·8 trillion and India $6·2 trillion (from 2012 to 2030), with cardiovascular disease being one of the most costly.6 Poor people in these countries are the worst affected, and with little access to preventive care they are also least likely to get evidence-based treatment and they have higher 30-day mortality outcomes.7 Cardiovascular disease is known to have devastating effects on individuals and families. In low-income and lower-middle-income countries, cardiovascular disease can push people to below the poverty line. In a study of the personal economic effect of cardiovascular disease hospitalisation in four lower-middle-income countries (India, China, Argentina, and Tanzania), catastrophic health spending likely to lead to impoverishment was present in more than 50% of the respondents in three of the countries (China, India, and Tanzania). Most participants also reported a decrease in self-reported health, loss of job, and decreases in family income and productivity. Distress financing and lost income were common, and resulted in people taking loans, selling assets, and consequently plunging into debt.8 Physical activity also lowers the risk of diabetes and cancers, lowers air pollution, and is good for the environment. Measures that boost physical activity in populations will also help achieve eight of the
www.thelancet.com Published online September 21, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32104-9
Published Online September 21, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)32104-9 See Online/Articles http://dx.doi.org/10.1016/ S0140-6736(17)31634-3
Danish Siddiqui/Reuters
In The Lancet, Scott A Lear and colleagues1 report results from a large cohort of 130 843 participants from 17 countries (including four low-income countries and seven middle-income countries) investigating the beneficial dose-dependent associations of all forms of physical activity with reduced mortality and cardiovascular disease risks.1 This is another confirmation that physical activity has definite and dose-dependent benefits for lowering risks of all-cause mortality and cardiovascular disease (heart attacks, stroke, and heart failure). What this Article contributes is evidence from low-income countries and middle-income countries on the benefits of physical activity from daily recreational and non-recreational activities, which includes physical activity at work, during household activities, and for transport. We already have robust evidence on the health benefits of physical activity,2,3 based primarily on studies from high-income countries. This study indicates that all types of physical activity are equally effective, and the protection accrued from physical activity in the current study that includes low-income countries and middleincome countries seems to be of similar magnitude. For example, in the context of benefits in lowering mortality, those meeting physical activity recommendations of at least 150 min of moderate activity per week had a 28% lower hazard ratio (HR) of mortality1 compared with a 22% lower risk ratio (RR) reported by Lee and colleagues.2 Similarly, Lear and colleagues1 report a 20% lower risk (HR) of cardiovascular disease (which includes coronary heart disease, stroke, and heart failure), while and Lee2 and Sattelmair3 and their colleagues reported a 14% lower risk (RR) of coronary heart disease. Additionally, the curvilinear shape of the dosedependent relation between physical activity and mortality and disease rates in Lear and colleagues’ study mirrors what has been observed in high-income countries,4 and provides an encouraging message: the largest risk reductions are seen between participants not meeting current physical activity recommendations and those meeting these recommendations—the equivalent of 150 min of moderate activity per week, from all forms of physical activity. For those willing to do more, additional risk reductions occurred at 150–750 min per week, and more than 750 min of activity per week, beyond which, risk reductions started to plateau.
1
Comment
UN Sustainable Developmental Goals.9 It is rare to find an intervention that has such powerful and far-reaching benefits across so many spheres. Creating a physical, social, and political environment where physical activity in daily living is desirable, accessible, and safe should be a developmental imperative; a planning, economic, social, and equity imperative; and a public health imperative. Parallel to pedestrian pavements, we need additional active transport roads for the many different modes of active transport along with cycling. It is important to note that the environment, dynamics, and context of lower-middle-income countries and low-income countries are different and pose many challenges, including rapid urbanisation, large populations, many different active and motorised transports on the roads, migration, wide socioeconomic disparities, rampant encroachment, air pollution, and high ambient temperatures, which can lead to heat exhaustion, dehydration, and decreased productivity, with potential for heat strokes. Trees on active transport roads, pavements, and lanes along with green spaces lower the ambient air temperature, help encourage breeze, lower the extreme heat, mitigate noise pollution, lower air pollution, and have a co-benefit of conserving fossil fuels by decreasing and avoiding artificial air cooling or conditioning and by promoting and making walking and cycling more comfortable. Trees and greenery in and around homes, workplaces, and schools are also known to have many health benefits, such as lowering risks of mortality, prostate cancer, and depression, and leading to better cognitive development and refraction.10,11 Open green spaces within 0·5 km radius12 of homes, workplaces, and educational institutes, encouraging participation in sports and local dances, wide pedestrian pavements, and limitations on the width of roads are some measures requiring urgent attention. In their quest for rapid development, governments in many low-income and lower-middle-income countries con centrate on construction and widening of roads for motorised transport at the cost of trees, green spaces, pedestrians, and other active transport priorities. However, a measure of development of a country is
2
how well we treat pedestrians and those using active transport. Promotion of physical activity, active transport, and active living by means of interventions contextualised to culture and context will have powerful and longlasting effects on population health and developmental sustainability. *Shifalika Goenka, I-Min Lee Indian Institute of Public Health, Public Health Foundation of India, and Center for Chronic Disease Control, New Delhi, India (SG); and Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA (I-ML) [email protected] We declare no competing interests. SG is supported by the Bernard Lown Scholars in Cardiovascular Health Program, Harvard T H Chan School of Public Health, and a Wellcome Trust (grant 096735/B/11/Z). 1
Lear SA, Hu W, Rangarajan S, et al. The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 highincome, middle-income, and low-income countries: the PURE study. Lancet 2017; published online Sept 21. http://dx.doi.org/10.1016/ S0140-6736(17)31634-3. 2 Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380: 219–29. 3 Sattelmair J, Pertman J, Ding EL, Kohl HW, III, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation 2011; 124: 789–95. 4 Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med 2015; 175: 959–67. 5 Roth GA, Johnson C, Abajobir A, et al. Global, regional, and national burden of cardiovascular diseases for 10 Causes, 1990 to 2015. J Am Coll Cardiol 2017; 70: 1–25. 6 Bloom DE, Cafiero ET, McGovern ME, et al. The macroeconomic impact of non-communicable diseases in China and India: estimates, projections, and comparisons. August, 2013. National Bureau of Economic Research. NBER working paper series, working paper 19335. http://pure.qub.ac.uk/portal/ files/17033974/McGovern_Economic_Impact_NCDs_JOEA_14.pdf (accessed July 26, 2017). 7 Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet 2008; 371: 1435–42. 8 Huffman MD, Rao KD, Pichon-Riviere A, et al. A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries. PLoS One 2011; 6: e20821. 9 The Bangkok Declaration on Physical Activity for Global Health and Sustainable Development. 2016. http://www.ispah.org/resources (accessed July 26, 2017). 10 James P, Hart JE, Banay RF, Laden F. Exposure to greenness and mortality in a nationwide prospective cohort study of women. Environ Health Perspect 2016; 124: 1344–52. 11 Demoury C, Thierry B, Richard H, Sigler B, Kestens Y, Parent ME. Residential greenness and risk of prostate cancer: a case-control study in Montreal, Canada. Environ Int 2017; 1998: 129–36. 12 Sallis JF, Cerin E, Conway TL, et al. Physical activity in relation to urban environments in 14 cities worldwide: a cross-sectional study. Lancet 2016 387: 2207–17.
www.thelancet.com Published online September 21, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32104-9