Introduction
Physical activity levels
Increased healthy and chronic disease survival
Limitations
How should this influence clinical practice?
References

 

Introduction

Physical activity in older people is critically important in the prevention of disease, promotion of health and maintenance of independence and improvement of quality of life.1

Previous work has reported that the percentage of older adults achieving recommended activity levels vary extensively, from 2.4-83% secondary to a wide variety of definitions of ‘recommended’ activity levels.1

There has been a need for studies that recruit representative random samples of community-based older adults and utilise validated physical activity methods consistently to enable comparison of physical activity levels over time.

To this end, the recently published Finnish study in Age and Ageing provides compelling evidence of the benefits of physical activity.2

Leskinen et al utilised data from the Finnish Public Sector (FPS) study. This was a nationwide study comprising of 151,901 employees with a >=6 month job contract of any year between 1991-2005 in 10 towns and five hospital districts in Finland. Following a baseline survey, four-yearly repeat surveys were collected with information obtained regarding five diseases (heart disease, stroke, chronic lung disease, cancer and diabetes) to estimate chronic disease-free life expectancy.

Physical activity levels

The study broke patients down into five categories of physical activity levels (inactive (30 mins exercise weekly) to vigorous active (>=4 hours weekly)) according to self-reported measures. This was then calculated into a metabolic equivalent (MET) based upon the nature and intensity of exercise alongside duration. Data was also collected on three occupational statuses at the first observation point and self-reported health status. Over the period of study, the authors applied multistate models to longitudinal data to obtain transition probabilities between health states.

The study included a total of 34,379 female patients (mean age 53.2 years) and 8,381 male patients (mean age 53.6 years). Overall 42% of men and 27% of women were categorised with high occupational status, and 34 and 17% with low occupational status respectively. At the first observation point, every third man and woman rated their health as sub-optimal and a quarter already had one chronic disease. Those in lower occupational groups were more commonly inactive compared to the highest occupational group (24 % vs. 15%) but there was no difference between the groups with the highest two activity levels. 

Increased healthy and chronic disease survival

The authors reported a clear dose-response relationship between higher physical activity levels and increased healthy and chronic disease survival life expectancy in men and women. On average vigorous active men and women lived 6.3 years longer in good health and 2.9 years without chronic disease between the ages of 50-75 years compared to inactive individuals. There was a larger improvement in patients in the lower of the three socioeconomic groups (6.7 years) likely felt to be secondary to a lower baseline line life expectancy and higher rates of chronic disease in this group.

The study is based upon a large prospective cohort with a high response rate and multiple measurements of self-rated disease and health over a long follow-up period. The statistical analyses, using microsimulation to estimate life expectancy and chronic disease-free life expectancy provides consistent results across the analysis period. Other novelties of the study include the estimation of health expectancy by physical activity levels in individuals having different occupational statuses, a comparison not previously performed.

Limitations

However, it should be noted that there are some limitations including the use of self-reporting scales. Self-reporting scales, although commonly used in this context, may be association with reporting and classification bias. Furthermore, the study was unable to exclude reverse causality whereby low physical activity levels at the first observational point were as a result of chronic disease. 

The authors' paper has extended previous data which reported that physical activity is associated with reduced prevalence of chronic disease,3 and lowered mortality risk4 in a dose-response manner. There are more specific benefits for older adults where physical activity has been shown to reduce cognitive decline and dementia5 and disability6 alongside improving endurance and strength.7 A recent systemic review commented that exercise interventions appear to be effective in managing the various components of frailty and preventing/delaying the onset of frailty, although the most effective exercise program remains unclear.8

How should this influence clinical practice?

In many regards it validates what we already know, however being able to quantify some of the benefits of physical activity is invaluable in the consulting room.

Firstly, the fact that patients who are in lower socioeconomic groups are those who have the most to gain from increasing physical activity levels. Focusing efforts to support and encourage these patients to increase physical activity may bear fruit, and with the expansion of social prescribing there is hope that clinicians may be supported in this aim. For example, locally in Fife there are local community centres (healthcare hubs) where patients can be referred for dietary and exercise support classes from selected patient deprivation groups. The third sector are also becoming actively involved in provision of social prescribing for health and well-being given broader cuts in the healthcare service.

Secondly, the nature of the dose-response relationship is really important to stress. For many patients walking through our doors, vigorous levels of weekly exercise may be unrealistic. However, it is reassuring to see in a long-term longitudinal study that increasing activity levels from inactive at all leads to improvements in overall health and chronic disease-free life expectancy. Thus, any improvement in overall activity levels can be commended. 

This study has reinforced the importance of physical activity in the future health and well-being of outpatients (and ourselves), and opportunistic health questioning in clinical practice may be of use to try and help and support patients to increase their activity levels.

Lloyd Hughes
GP Registrar, Pediatric Medicine, NHS Fife

 

Conflict of interest: none declared

 

References

1. Sun F, Norman IJ, While AE. Physical activity in older people: a systematic review. BMC Public Health. 2013; 13: 449.

2. Leskinen T, Stenholm S, Aalto V et al. Physical activity level as a predictor of healthy and chronic disease-free expectancy between ages 50-75. Age and Ageing. 2018; 47: 423-429.

3. Kyu HH, Bachman VF, Alexander LT et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. Br Med J 354:i3857

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 175: 959-67.

5. Blondell SJ, Hammersley-Mather R, Veerman JL. Does physical activity prevent cognitive decline and dementia?: A systematic review and meta-analysis of longitudinal studies. BMC Public Health. 2014. 14: 510

6. Tak E, Kuiper R, Chorus A et al. Prevention of onset and progression of basic ADL disability by physical activity in community dwelling adults: a meta-analysis. Ageing Res Rev 12: 329-38

7. Ferreira ML, Sherrington C, Smith K et al. Physical activity improves strength, balance and endurance in adults aged 40-65 years: a systematic review. J Physiother 58: 145-56.

8. Silva RB1, Aldoradin-Cabeza H, Eslick GD et al. The Effect of Physical Exercise on Frail Older Persons: A Systematic Review. J Frailty Aging. 2017;6(2):91-96