Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Aug 21;366:l4570.
doi: 10.1136/bmj.l4570.

Dose-response Associations Between Accelerometry Measured Physical Activity and Sedentary Time and All Cause Mortality: Systematic Review and Harmonised Meta-Analysis

Free PMC article

Dose-response Associations Between Accelerometry Measured Physical Activity and Sedentary Time and All Cause Mortality: Systematic Review and Harmonised Meta-Analysis

Ulf Ekelund et al. BMJ. .
Free PMC article


Objective: To examine the dose-response associations between accelerometer assessed total physical activity, different intensities of physical activity, and sedentary time and all cause mortality.

Design: Systematic review and harmonised meta-analysis.

Data sources: PubMed, PsycINFO, Embase, Web of Science, Sport Discus from inception to 31 July 2018.

Eligibility criteria: Prospective cohort studies assessing physical activity and sedentary time by accelerometry and associations with all cause mortality and reported effect estimates as hazard ratios, odds ratios, or relative risks with 95% confidence intervals.

Data extraction and analysis: Guidelines for meta-analyses and systematic reviews for observational studies and PRISMA guidelines were followed. Two authors independently screened the titles and abstracts. One author performed a full text review and another extracted the data. Two authors independently assessed the risk of bias. Individual level participant data were harmonised and analysed at study level. Data on physical activity were categorised by quarters at study level, and study specific associations with all cause mortality were analysed using Cox proportional hazards regression analyses. Study specific results were summarised using random effects meta-analysis.

Main outcome measure: All cause mortality.

Results: 39 studies were retrieved for full text review; 10 were eligible for inclusion, three were excluded owing to harmonisation challenges (eg, wrist placement of the accelerometer), and one study did not participate. Two additional studies with unpublished mortality data were also included. Thus, individual level data from eight studies (n=36 383; mean age 62.6 years; 72.8% women), with median follow-up of 5.8 years (range 3.0-14.5 years) and 2149 (5.9%) deaths were analysed. Any physical activity, regardless of intensity, was associated with lower risk of mortality, with a non-linear dose-response. Hazards ratios for mortality were 1.00 (referent) in the first quarter (least active), 0.48 (95% confidence interval 0.43 to 0.54) in the second quarter, 0.34 (0.26 to 0.45) in the third quarter, and 0.27 (0.23 to 0.32) in the fourth quarter (most active). Corresponding hazards ratios for light physical activity were 1.00, 0.60 (0.54 to 0.68), 0.44 (0.38 to 0.51), and 0.38 (0.28 to 0.51), and for moderate-to-vigorous physical activity were 1.00, 0.64 (0.55 to 0.74), 0.55 (0.40 to 0.74), and 0.52 (0.43 to 0.61). For sedentary time, hazards ratios were 1.00 (referent; least sedentary), 1.28 (1.09 to 1.51), 1.71 (1.36 to 2.15), and 2.63 (1.94 to 3.56).

Conclusion: Higher levels of total physical activity, at any intensity, and less time spent sedentary, are associated with substantially reduced risk for premature mortality, with evidence of a non-linear dose-response pattern in middle aged and older adults.

Systematic review registration: PROSPERO CRD42018091808.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.


Fig 1
Fig 1
Study selection
Fig 2
Fig 2
Dose-response associations between total physical activity (top left), light intensity physical activity (LPA) (top right), low LPA (middle left), high LPA (middle right), moderate-to-vigorous intensity physical activity (MVPA) (bottom left), and sedentary time (bottom right, data from REGARDS (Reasons for Geographic and Racial Differences in Stroke) and FHS (Women’s Health Study) are only included for MVPA) and all cause mortality. Modelling performed using restricted cubic splines with knots at 25th, 50th, and 75th centiles of exposure specific distribution from medians of quarters (least to most active). The exposure reference is set as the median of the medians in the reference group (least active) (see supplementary table 3). Knot locations are available in supplementary table 8. cpm=counts per minute

Comment in

Similar articles

See all similar articles

Cited by 25 articles

See all "Cited by" articles


    1. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. U.S. Department of Health and Human Services, 2018.
    1. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, Lancet Physical Activity Series Working Group Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012;380:219-29. 10.1016/S0140-6736(12)61031-9 - DOI - PMC - PubMed
    1. Ding D, Lawson KD, Kolbe-Alexander TL, et al. Lancet Physical Activity Series 2 Executive Committee The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet 2016;388:1311-24. 10.1016/S0140-6736(16)30383-X - DOI - PubMed
    1. Biswas A, Oh PI, Faulkner GE, et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med 2015;162:123-32. 10.7326/M14-1651 - DOI - PubMed
    1. Patterson R, McNamara E, Tainio M, et al. Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis. Eur J Epidemiol 2018;33:811-29. 10.1007/s10654-018-0380-1 - DOI - PMC - PubMed

Publication types