Physical Activity to Prevent CVD Across the Lifespan: Local and Global Burden

Thank you to Kashica J. Webber-Ritchey, and Elizabeth Moxley, for this article on physical activity and its local and global burden.

Cardiovascular disease (CVD) is the leading global cause of death for all individuals, irrespective of gender, race, or ethnic background.1,2 In the U.S., myocardial infarction occurs every 40 seconds and results in death every 36 seconds.3 CVD-related deaths resulting in lost productivity from health care services and drug treatment amounted to approximately $363 billion per year from 2016 to 2017.3 Perhaps more concerning is the stalled decline in CVD mortality which is, in part, due to a lack of effectively translating clinical findings into practice and into public health.4

Physical inactivity is the most important public health problem of the 21st century5and of urgent worldwide concern,6 sufficient for the WHO to warrant priority interventions to increase physical activity engagement.6 Current global estimates reveal that up to 80% of U.S. adults and 81% of adolescents do not engage in adequate quantities of physical activity according to the recent guidelines of a minimum of 150 to 300 minutes per week of moderate-intensity aerobic and muscle-strengthening activity.7,8 These estimates are increasing,9,10 irrespective of age, culture, race, gender, and ethnic background.11 Non-White populations consistently report lower physical activity levels,12 suggesting existing disparities according to subgroups (23.4% of non-Hispanic White adults, 30.3% non-Hispanic Black, and 31.7% of Hispanic adults).11

Today’s U.S. youth are not exempt: a dramatic decrease in physical activity is evident13 according to gender, age, ability, and environmental factors (i.e., neighborhood). Less than one in four children14 between 6 to 17 years of age meet the current recommendations of at least one hour of physical activity per day. According to the WHO,15 urgent action is needed to increase physical activity in girls and boys ages 11-17 based on recent findings10 in which 85% of girls and 78% of boys do not meet current recommendations. Furthermore, in 2017, only 26.1% of high school students participated in at least 60 minutes per day of physical activity all 7 days of the previous week, and only 29.9% of high school students attended physical education classes daily.15,16

Links Between Physical Activity, Health Risks, and Social Determinants of Health

In the U.S., decreased physical activity engagement in adults and youth is associated with an increased risk for CVD, type 2 diabetes, breast and colon cancer, and bone and joint problems.17 Decreased physical activity engagement is also one of six leading causes of mortality and morbidity associated with the social problems of (1) unintentional injuries and violence, (2) tobacco use, (3) alcohol and other drug use, (4) sexual behaviors related to unintended pregnancy and sexually transmitted infections, and (5) unhealthy dietary behaviors.16

To ensure healthy aging and prevent the progression to the development of CVD, strategies to promote ideal cardiovascular health should begin in childhood.4 CVD is influenced by social determinants of health (SDOH) – those conditions that are related to where one is born, lives, learns, works, plays, worships, and ages.18 SDOH such as social and community context, economic stability, and access to a quality education may create barriers to cardiovascular prevention and treatment. The incidence of CVD has been found to be greater in middle- and low-income countries due to tobacco use and elevated blood pressure and lipid levels.

Health Benefits of Physical Activity on Cardiovascular Health

The benefits of physical activity for the prevention and treatment of CVD have been well-established for decades. Yet, inadequate physical activity continues to be highly prevalent worldwide;9,19 current trends indicate the 2025 global physical activity target of a 25% relative reduction in insufficient physical activity will not be met.10 Physical activity –any bodily movement produced by skeletal muscle contraction resulting in increased energy expenditure,7 –offers a strong inverse dose-response relationship to CVD risk and fatal and non-fatal CVD events.20-22 Conversely, a lack of physical activity quantity according to the physical activity guidelines23 contributes to CVD at a rate similar to hypertension, hypercholesterolemia, and smoking.20  Physical activity protects against systemic cardiovascular-related morbidities such as the risk of ischemic stroke,24 stroke recurrence in post-stroke patients,25 antiatherogenic effects in the vasculature,19 and increased small, dense low-density lipoprotein cholesterol (sdLDL-C).26 As an example, routine physical activity engagement in higher quantities improved post-prandial lipid response in the Amish compared with their sedentary counterparts.27

Recent reports28 emphasize that higher levels of fitness offer the most protective mortality benefits. The benefits from greater exertion were initially demonstrated in the landmark studies of Paffenbarger et al.29 In a 22-year follow-up sample of 3,975 San Francisco longshoremen who were followed for 57,632 man-years, 410 fatal cases of myocardial infarction were observed after adjusting for age, race, systolic blood pressure, smoking, body mass index, glucose intolerance, and the individual’s electrocardiogram. The findings demonstrated those with high-energy work activity of 7 kcal/min demonstrated half the rate of a fatal myocardial infarction than those in the lowest energy work group of 1 kcal/min.

Impacts of Major Life Events and Transition Periods on Physical Activity

According to a recent American Heart Association scientific statement on life transitions and events,30 physical activity habits across the lifespan may change in response to common life events and transitions.31 A life event is a singular occurrence, a biological, psychological, social, and environmental event that marks a change in status requiring readjustment which may trigger a transition. Transitions refer to status passages that temporally exceed the duration of life events.31 Physical activity typically decreases during education-related events and transitions (entry to elementary, middle or high school, and entry to college/university), family-related events (pregnancy, parenthood); employment-related events (entry into labor market, and retirement), relationship-related events (marriage or civil union) and entering a long-term care facility.30

Implications for Clinical Practice

Perhaps most concerning is the fact that of those who are physically active, a substantial percentage engage in low or very low levels of activity,32 indicating the important role of all health care providers in promoting physical activity. Perhaps the simplest step is to ask questions related to physical activity engagement, such as how much time one spends being physically active as well as educating individuals about the numerous health benefits that result from physical activity.20

Nurses are instrumental in facilitating physical activity engagement across the lifespan, especially cardiovascular nurses who should also adopt these lifestyle changes to lead by example.33 Along with other health care providers, nurses can help their patients establish and achieve physical activity goals by monitoring progress toward meeting these goals, seeking support to maintain physical activity, using positive self-reward to reinforce progress, and encouraging structured problem-solving to prevent relapsing to an inactive lifestyle.7 The most significant behavioral risk factors (heart disease and stroke) are due to unhealthy lifestyle habits. By controlling diet, physical activity, tobacco, and harmful alcohol use, CVD risk can be reduced. Such habits can be measured in primary care facilities to identify risk.2

Addressing barriers related to SDOH may reduce physical activity disparities in under-resourced communities. Collaboration among nurses, other medical providers, public health, and policy professionals,34 can address cost and time requirements to modify the built environment.35 Clinicians can be cognizant of neighborhood-related factors such as perceived neighborhood safety when providing physical activity counseling.20 Clinicians may evaluate SDOH and motivation to address physical activity habits.36 Health policies creating affordable and available environments to encourage healthy habits help to motivate individuals for sustainable physical activity engagement. Further exploration between barriers to physical activity and factors that encourage or motivate individuals to engage in physical activity in the community to improve cardiovascular health is currently warranted.35

Physical Activity Resources for the Clinical Toolkit

  • The Community Guide, by the Community Preventive Services Task Force. Sponsored by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), and Community Preventive Services Task Force.
  • Exercise is Medicine, an action guide for health care providers and physical activity toolkit for registered dieticians by the American College of Sports Medicine.
  • NFL Play 60 is an app for youth by the American Heart Association (AHA) and the National Football League.
  • Move More Together – exercise videos and fitness information by the AHA.
  • Active People, Healthy Nation: Healthcare Tool – physical activity strategies by the CDC.
  • The Move Your Way Community Resources – Free tools and resources on Physical Activity Guidelines by the Office of Disease Prevention and Health Promotion
  • Health Healhty Toolbox, a series of lifestyle change patient education tools which includes 8 sheets on physical activity.


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