Step Counts Under 5000 Still Tied to Lower Death Risk

Marilynn Larkin

August 10, 2023

Higher daily step counts were associated with reduced risk of all-cause mortality and cardiovascular mortality, with benefit beginning with any amount over about 4000 and 2300 steps, respectively, in a new meta-analysis.

More steps were better ― additional benefit was seen with increasing increments of 500 or 1000 steps.

"One of our main aims was to overcome all the inconsistencies in previous studies, where the optimal number of daily steps for health benefits was usually between 6000 and 10,000," Maciej Banach, MD, PhD, of the Medical University of Lodz, Poland, told | Medscape Cardiology.

"As a preventive cardiologist, I saw that many of my patients were discouraged and said it's impossible when I told them that making lifestyle changes included taking at least 7000 daily steps," he said.

"But our study in relatively healthy individuals, not patients, showed even a lower number ― for example, around 4000 ― may be associated with a significant reduction of mortality.

"I tell people to start early, be regular, and don't worry about the initial baseline number, because it's important to start and it's important to improve," he said. "Our study showed that if we increase the number of steps per day, every 500- to 1000-step increase might still be associated with an additional mortality reduction of 7% to 15%."

The study was published online August 9 in the European Journal of Preventive Cardiology.

Every Move Counts

The investigators searched the literature through June 2022 and selected 17 cohort studies with 226,889 participants and a median follow-up of 7.1 years for inclusion in the analysis: 10 studies reported all-cause mortality; four reported CV mortality; and three reported both outcomes.

The mean age of the participants was 64.4 years, and half were women. Daily step counts in the included studies were objectively measured for at least 7 consecutive days.

As noted, a 1000-step increment was associated with a 15% decrease in risk of all-cause mortality (hazard ratio [HR], 0.85); a 500-step increment was associated with a 7% decrease in CV mortality (HR, 0.93).

Compared with the reference quartile (median steps/day, 3967), quartile 1 (median steps, 5537) was associated with a 48% lower risk of all-cause mortality; quartile 2 (median steps, 7370), with a 55% lower risk; and quartile 3 (median steps, 11,529), with a 67% risk reduction.

Similarly, compared with the lowest quartile of steps per day used as reference (median steps, 2337), higher quartiles of steps per day (Q1, 3982; Q2, 6661; and Q3, 10,413) were linearly associated with a reduced risk of CV mortality (16%, 49%, and 77%, respectively).

In a restricted cubic splines model, a nonlinear dose-response association was observed between step count and all-cause and CV mortality, with a progressively lower risk of mortality with an increase in step count.

Dose-response curves were similar for men and women. However, there was a difference by age: Among people aged 60 years or older, the size of the risk reduction was smaller. Among the older adults, there was a 42% risk reduction for those who walked between 6000 and 10,000 steps daily, compared with a 49% reduction in risk among younger adults who walked between 7000 and 13,000 steps a day.

For both groups, daily step counts higher than 5000 resulted in a "dramatically" lower risk of all-cause mortality.

An analysis that compared the impact of climate regions on the associations showed no significant effect on all-cause mortality. People in all climate zones benefited when the daily step count exceeded ~5500.

Even given the encouraging study results, "we know very well that every kind of exercise is critically important," Banach said. It is easier to focus on step counts because the counts can be monitored and calculated with smartwatches, pedometers, and other tools. That also makes it easier to check associations and outcomes for large groups of patients.

"But in fact, we should not be focusing on one type of exercise, such as walking or running," he said. "We can dance, ride bicycles, and do many other different exercises that mobilize our hearts.

"We also know that in all these activities, including steps, people have different capabilities ― for example, some can walk more slowly, others faster and with more intensity."

Banach recommends following the European and US physical activity guidelines that advise, in addition to muscle-strengthening activities, 150 minutes of moderate-intensity aerobic training weekly, or 75 minutes of vigorous-intensity aerobic activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity.

From the results he sees in patients, he believes the combination approach is probably best for the heart.

Furthermore, he said, it's important to exercise regularly, something that's easier if individuals enjoy what they're doing. "The type of training or whether you are completely inactive or very active at the start doesn't matter, because any improvement, any addition to the to the baseline values will have health benefits," he concluded.

Higher Goals Helpful

Three experts commented on the study for | Medscape Cardiology. All noted that the results are in line with previous studies, that the observational nature of the study is a limitation, and that additional randomized, controlled trials are needed to confirm the findings.

Evan Brittain, MD, an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tennessee, expressed some additional concerns.

Brittain was principal investigator of a recent study that found that the relationship between steps per day and incident disease was inverse and linear for obesity, sleep apnea, gastroesophageal reflux disease, and major depressive disorder. Daily step counts above 8200 were associated with protection from incident disease.

He noted that in the current study, "the authors chose to make the least active quartile (25%) the reference group (only 3967 steps/day for all-cause mortality and only 2337 steps/day for CV mortality analysis), which somewhat lowers the bar for finding a significant benefit at higher step counts.

"Moreover, in the spline analyses, zero steps per day is used as the comparison, which is not a practical, real-world comparison," he said. "As a result, those data are very hard to interpret, and I think are overstated."

Like Banach, Brittain said he would continue to advise following guideline recommendations to get 150 minutes per week of moderate-intensity activity. However, he added that although it is reasonable to advise patients that benefits do accrue with daily step counts of less than 10,000, "I would not want patients to misconstrue from this study that getting more than only 2330 steps per day is a beneficial goal."

Martin Halle, MD, a professor in the Department of Prevention and Sports Medicine at the Technical University of Munich, said, "From a clinical, medical and health perspective, the general population should aim for 5000 steps, which is about 3–4 kilometers [about 2 miles] of walking, and intensity counts ― the faster you walk, the better.

"I recommend doing 100 steps fast and 100 steps slow and then 100 steps fast and 100 steps slow," said Halle, who is past president of the European Association of Preventive Cardiology. This approach not only motivates people, "but they improve their exercise capacity substantially and very quickly, just within weeks."

European Society of Cardiology Vice President and European Journal of Preventive Cardiology Editor-in-Chief Massimo Piepoli, MD, PhD, agrees that "little is better than nothing and more is even better. This applies to healthy subjects, as well as patients with chronic diseases.

"Five hundred steps is a very short distance (such as walking 2 blocks or walking the dog for about 10–15 minutes every day)," he said. Yet, increasing step counts in increments of 500 "is associated with a significant reduction in cardiovascular mortality both in men and women, particularly in older individuals.

"We do not need to depend on expensive gym facilities," he added. "But at the same time, we need to live in and to promote the building of neighborhoods where it is possible to walk in a safe and healthy environment."

The research received no external funding. Banach has disclosed the following: speakers bureau: Amgen, Daiichi Sankyo, Kogen, KRKA, Polpharma, Novartis, Novo-Nordisk, Sanofi-Aventis, Teva, Viatris, Zentiva; consultant to Amgen, Daiichi Sankyo, Esperion, Freia Pharmaceuticals, NewAmsterdam, Novartis, Novo-Nordisk, Polfarmex, Sanofi-Aventis; Grants from Amgen, Daiichi Sankyo, Sanofi, Valeant, and Viatris, CMDO at Longevity Group; CMO at Nomi Biotech Corporation. Disclosures for co-authors are available in the original article.

Eur J Prev Cardiol. Published online August 8, 2023. Full text

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