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People who are physically active have at least a 30% lower risk of death during follow-up compared with those who are inactive. However, the ideal dose of exercise for improving longevity is uncertain. The aim of this study was to investigate the association between jogging and long-term, all-cause mortality by focusing specifically on the effects of pace, quantity, and frequency of jogging. As part of the Copenhagen City Heart Study, 1,098 healthy joggers and 3,950 healthy nonjoggers have been prospectively followed up since 2001. Cox proportional hazards regression analysis was performed with age as the underlying time scale and delayed entry. Compared with sedentary nonjoggers, 1 to 2.4 h of jogging per week was associated with the lowest mortality (multivariable hazard ratio [HR]: 0.29; 95% confidence interval [CI]: 0.11 to 0.80). The optimal frequency of jogging was 2 to 3 times per week (HR: 0.32; 95% CI: 0.15 to 0.69) or ≤1 time per week (HR: 0.29; 95% CI: 0.12 to 0.72). The optimal pace was slow (HR: 0.51; 95% CI: 0.24 to 1.10) or average (HR: 0.38; 95% CI: 0.22 to 0.66). The joggers were divided into light, moderate, and strenuous joggers. The lowest HR for mortality was found in light joggers (HR: 0.22; 95% CI: 0.10 to 0.47), followed by moderate joggers (HR: 0.66; 95% CI: 0.32 to 1.38) and strenuous joggers (HR: 1.97; 95% CI: 0.48 to 8.14). The findings suggest a U-shaped association between all-cause mortality and dose of jogging as calibrated by pace, quantity, and frequency of jogging. Light and moderate joggers have lower mortality than sedentary nonjoggers, whereas strenuous joggers have a mortality rate not statistically different from that of the sedentary group. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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ORIGINAL INVESTIGATIONS
Dose of Jogging and Long-Term Mortality
The Copenhagen City Heart Study
Peter Schnohr, MD, DMSC,*James H. OKeefe, MD,yJacob L. Marott, MSC,*Peter Lange, MD, DMSC,*z
Gorm B. Jensen, MD, DMSC*x
ABSTRACT
BACKGROUND People who are physically active have at least a 30% lower risk of death during follow-up compared
with those who are inactive. However, the ideal dose of exercise for improving longevity is uncertain.
OBJECTIVES The aim of this study was to investigate the association between jogging and long-term, all-cause
mortality by focusing specically on the effects of pace, quantity, and frequency of jogging.
METHODS As part of the Copenhagen City Heart Study, 1,098 healthy joggers and 3,950 healthy nonjoggers have been
prospectively followed up since 2001. Cox proportional hazards regression analysis was performed with age as the un-
derlying time scale and delayed entry.
RESULTS Compared with sedentary nonjoggers, 1 to 2.4 h of jogging per week was associated with the lowest mortality
(multivariable hazard ratio [HR]: 0.29; 95% condence interval [CI]: 0.11 to 0.80). The optimal frequency of jogging was
2 to 3 times per week (HR: 0.32; 95% CI: 0.15 to 0.69) or #1 time per week (HR: 0.29; 95% CI: 0.12 to 0.72). The optimal
pace was slow (HR: 0.51; 95% CI: 0.24 to 1.10) or average (HR: 0.38; 95% CI: 0.22 to 0.66). The joggers were divided
into light, moderate, and strenuous joggers. The lowest HR for mortality was found in light joggers (HR: 0.22; 95%
CI: 0.10 to 0.47), followed by moderate joggers (HR: 0.66; 95% CI: 0.32 to 1.38) and strenuous joggers (HR: 1.97; 95%
CI: 0.48 to 8.14).
CONCLUSIONS The ndings suggest a U-shaped association between all-cause mortality and dose of jogging as
calibrated by pace, quantity, and frequency of jogging. Light and moderate joggers have lower mortality than sedentary
nonjoggers, whereas strenuous joggers have a mortality rate not statistically different from that of the sedentary
group. (J Am Coll Cardiol 2015;65:4119) © 2015 by the American College of Cardiology Foundation.
The most famous case of sudden death in
connection with running is that of Pheidippi-
des, a professional running courier who in
490B.C.isbelievedtohaverunfromMarathon
to Athens, Greece, a distance of approximately 25
miles, to bring news of the Athenian victory over
the Persians. Upon reaching the Athenian Agora, he
exclaimed Nike!(victory), collapsed, and died.
Some historians, believing this is a myth, favor
another version: that after his run from Marathon to
Athens, Pheidippides continued to Sparta for military
help.HeranthedistancefromAthenstoSparta,
137 miles, in 48 h (1).
In 1953, Morris et al. (2) published a paper showing
that mortality from coronary heart disease (CHD) was
more than twice as high in sedentary London bus
From the *Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen, Denmark; ySaint Lukes Mid America Heart
Institute and University of Missouri-Kansas City, Kansas City, Missouri; zDepartment of Respiratory Medicine, Hvidovre Hospital,
and Section of Social Medicine, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark; and the xDepartment
of Cardiology, Hvidovre Hospital, Copenhagen, Denmark. Supported by the Danish Heart Foundation. The authors have reported
that they have no relationships relevant to the contents of this paper to disclose.
Manuscript received September 10, 2014; revised manuscript received October 14, 2014, accepted November 4, 2014.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 65, NO. 5, 2015
ª2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2014.11.023
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drivers compared with physically active
conductors. This pioneering work gave rise to
the hypothesis that physical activity might be
of importance in prevention of CHD.
As part of a report from the Presidents
Council on Youth Fitness, a message in 1965
from President Lyndon B. Johnson stated the
following: Medical evidence tells us that our hearts,
lungs, muscles and even our minds need the effects
of regular and vigorous exercise(3).Sincethen,
numerous recommendations about physical tness in
leisure time have been published, and they have in
general recommended that every adult should
perform >30 min of moderate-intensity physical ac-
tivity preferably every day of the week. National
guidelines also call for a combination of moderate-
and vigorous-intensity activity, such as walking
briskly for 30 min twice a week and then jogging for
20 min on 2 other days. The data strongly support
an inverse association between regular exercise and
mortality. In longitudinal studies, physically active
men and women have an approximately 30% lower
riskofdeathduringfollow-upcomparedwithinac-
tive people. No upper threshold for physical activity
has ever been recommended (46).
In 1969, the rst running race in Europe (the Ere-
mitage Race) took place in Denmark; 2,344 men and
women nished the distance of 7.6 miles. Unfortu-
nately, a 46-year-old naval ofcer died of a myocar-
dial infarction during this event. As a result of this
death, the event organizers hesitated to continue
running races, reasoning that perhaps they were too
strenuous and possibly dangerous for the general
population. (The race has continued and has gained
in popularity.) Subsequently, during the 1970s, when
jogging gained momentum, several reports of deaths
during jogging were published (713).
The Copenhagen City Heart Study (14,15) reported
that the relative intensity of walking and cycling and
not the duration was of most importance in relation
to all-cause and CHD mortality. Subsequently, the
Copenhagen City Heart Study showed that the in-
crease in survival among joggers was 6.2 years in
men and 5.6 years in women. This particular analysis
was performed in a random sample of 1,878 joggers
who were followed for up to 35 years and compared
with 16,827 nonjoggers. Jogging up to 2.5 h per
week at a slow or average pace and a frequency of
#3 times per week was associated with the lowest
mortality. Those who jogged >4 h per week, at a fast
pace, and >3 times per week appeared to lose many
of the longevity benets noted with less strenuous
doses of jogging (16).Thisnding was somewhat
surprising.
Inthepresentstudy,weexploreinmoredetail
whether a U-shaped association exists between mor-
tality and dose of jogging as calibrated by pace,
quantity, and frequency of jogging.
METHODS
STUDY POPULATION. The prospective Copenhagen
City Heart Study is composed of a random sample
of 19,329 white men and women between 20 and
93 years of age drawn from the Copenhagen Popula-
tion Register as of January 1, 1976. The current study
used the fourth examination from 2001 to 2003.
All subjects from the original sample were invited
to all subsequent examinations, and a new random
sample of younger men and women was included.
Details have been described elsewhere (1,17).
In the present analyses, we excluded participants
with a history of CHD (n ¼513), stroke (n ¼262), and
cancer (n ¼469), leaving 5,048 men and women
(1,098 healthy joggers and 3,950 healthy nonjoggers)
for analyses.
SURVEY METHODS. Established procedures and ex-
aminations for cardiovascular (CV) epidemiological
surveys were used (18). Physical activity in leisure
timewasgradedas1of4levelsinall4surveys
using The Copenhagen City Heart Study Leisure
Time Physical Activity Questionnaire (1). Levels of
activity were dened as follows: group I, almost
entirely sedentary (e.g., reading, watching television
or movies, engaging in light physical activity, such
as walking or biking for <2 h per week); group II,
light physical activity for 2 to 4 h per week;
group III, light physical activity for more than 4 h per
week or more vigorous activity for 2 to 4 h per week
(e.g., brisk walking, fast biking, heavy gardening,
sports that cause perspiration or exhaustion); and
group IV, high vigorous physical activity for more
than 4 h per week or regular heavy exercise or
competitive sports several times per week. The activity
questionnaire has been shown to discriminate be-
tween sedentary people and their more active coun-
terparts with respect to maximal oxygen uptake (19).
In the 2001 to 2003 survey, we included questions
on the weekly quantity of jogging, frequency of
jogging, and the subjects own perception of pace
(slow, average, fast). We found that a relative scale of
pace (intensity) is more appropriate than an absolute
scale when the age span is very wide (20 to 95 years)
and when the participants have wide differences
in levels of physical tness.Comparedwiththe
SEE PAGE 420
ABBREVIATIONS
AND ACRONYMS
CHD =coronary heart disease
CI =condence interval
CV =cardiovascular
DM =diabetes mellitus
HR =hazard ratio
METs =metabolic equivalents
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nonjoggers in group I (almost entirely sedentary), the
hazard ratio (HR) of mortality for joggers by pace,
quantity, and frequency of jogging was calculated.
The joggers also were subdivided into 3 groups ac-
cording to dose of jogging (Table 1). Light joggers
had a slow or average pace, approximately 5 miles
per hour (corresponding to 6 metabolic equivalents
[METs]), and <2.5 h of jogging per week with a fre-
quency of #3 times per week. Moderate joggers had
asloworaveragepace,$2.5 h of jogging per week
with a frequency of #3 times per week or fast pace,
#4 h of jogging per week with a frequency of #3times
per week or slow or average pace with a frequency of
>3 times per week or fast pace, <2.5 h of jogging per
week with a frequency of >3 times per week. Stren-
uous joggers had a fast pace of more than 7 miles per
hour ($12 METs) and either >4 h of jogging per week
or $2.5 h of jogging per week with a frequency of
>3 times per week.
A self-administered questionnaire regarding phys-
ical activity, smoking, alcohol consumption, socio-
economic status, CHD, stroke, lung disease, cancer,
diabetes mellitus (DM), and family history was
completed and reviewed. Height, weight, and blood
pressure (London School of Hygiene sphygmoma-
nometer) as well as results of electrocardiography
and data from a comprehensive investigation of a
blood sample were obtained (17).
The Committee on Biomedical Research Ethics
for the Capital Region in Denmark (H-KF-01-144/01)
approved the study. All participants gave written
consent.
ENDPOINTS. Participants were followed up from
their rst examination to April 2013 or death by using
their unique personal identication number in the
national Danish Central Person Register (all-cause
deaths). During the observation period, Denmark
shifted from the 8th revision of the International
Classication of Diseases to the 10th revision. All
hospital admissions were obtained from the national
Danish Patient Registry from 1977 to April 2013 for
CHD codes 410 to 414 until January 1994 and there-
after codes I20 to I25, for stroke codes 430 to 438
andI60toI68orG45,andforcancercodes140to209
and C00 to D09. The completion rate of follow-up for
death was nearly 100%.
STATISTICAL ANALYSIS. For demographics, Fisher
exact test was used for categorical variables and
analysis of variance for continuous variables of pace,
quantity, and frequency of jogging.
In the multivariable analyses, we adjusted for the
following potential confounders: age, sex, smoking
(never, former, 1 to 14 g/day of tobacco, $15 g/day of
tobacco; 1 cigarette ¼1 g of tobacco, 1 cheroot ¼3g
of tobacco, and 1 cigar ¼5 g of tobacco), alcohol
intake (never, 1 to 21 drinks/week for men and
1to14drinks/weekforwomen,>21 drinks/week for
men and >14 drinks/week for women), education
(<8years,8to10years,>10 years in school), and
DM (self-reported or a nonfasting blood glucose
level $200 mg/dl).
The association between jogging and all-cause
mortality was examined with Cox proportional haz-
ards regression analysis, with age as the underlying
time scale and delayed entry accordingly. The as-
sumption of proportionality in the Cox regression
modelwastestedwiththeLin,Wei,andYingscore
process test (20).
RESULTS
Baseline characteristics at the 2001 to 2003 exami-
nation of the sedentary nonjoggers and joggers,
stratied by their quantity, frequency, and pace of
jogging, are presented in Table 2. At baseline, 1,098
were joggers (593 men and 505 women) and 413 were
sedentary nonjoggers. The latter group represented
9% of our population 50 years of age and older. We
registered 28 deaths among joggers and 128 deaths
among sedentary nonjoggers. In general, the joggers
were younger, had lower blood pressure and body
mass index, and had a lower prevalence of smoking
and DM. There was a massive overlap in age range
between joggers (20 to 86 years) and sedentary non-
joggers (21 to 92 years). The exible age adjustment
ensured by the Cox model made comparisons
TABLE 1 Joggers Categorized as Light Joggers, Moderate Joggers, or Strenuous Joggers on the Basis of Self-Reported Pace, Quantity,
and Frequency of Jogging
Jogging Pace
Slow Average Fast
<2.5 h/week 2.54h/week >4h/week <2.5 h/week 2.54h/week >4h/week <2.5 h/wee k 2.54h/week >4h/week
Frequency of jogging
#3 times/week Light Moderate Moderate Light Moderate Moderate Moderate Moderate Strenuous
>3 times/week Moderate Moderate Moderate Moderate Moderate Moderate Moderate Strenuous Strenuous
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TABLE 2 Baseline Characteristics for the 1,098 Joggers and 413 Sedentary Nonjoggers in the Copenhagen City Heart Study
Sedentary
Nonjoggers
Joggers: Quantity of Jogging
(h/week)
Joggers: Frequency of Jogging
(times/week) Joggers: Jogging Pace
Joggers: Combination of
Quantity/Frequency/Pace
(n ¼413)
#1
(n ¼640)
12.4
(n ¼286)
2.54
(n ¼122)
>4
(n ¼50) p Value
#1
(n ¼323)
23
(n ¼474)
>3
(n ¼84) p Value
Slow
(n ¼178)
Average
(n ¼704)
Fast
(n ¼201) p Value
Light
(n ¼576)
Moderate
(n ¼262)
Strenuous
(n ¼40) p Va lue
Age, yrs 61.3 16.2 44.2 13.9 40.5 13.6 40.2 13.0 38.8 13.1 <0.001 41.3 13.3 41.2 13.3 45.7 15.2 0.02 45.1 14.9 42.9 13.4 38.4 12.9 <0.001 42.3 13.6 40.9 13.2 37.0 13.9 0.03
Men 178 (43.1) 331 (51.7) 150 (52.4) 76 (62.3) 36 (72.0) 0.009 189 (58.5) 251 (53.0) 51 (60.7) 0.19 58 (32.6) 375 (53.3) 153 (76.1) <0.001 283 (49.1) 176 (67.2) 32 (80.0) <0.001
Smoking 0.24 0.09 0.02 0.06
Never 105 (26.0) 294 (46.6) 136 (48.1) 52 (45.2) 24 (51.1) 157 (49.5) 221 (47.6) 38 (47.5) 75 (42.4) 314 (45.3) 112 (58.3) 267 (46.8) 123 (48.8) 24 (66.7)
Former 106 (26.2) 171 (27.1) 85 (30.0) 42 (36.5) 10 (21.3) 85 (26.8) 135 (29.1) 29 (36.3) 50 (28.2) 202 (29.1) 50 (26.0) 159 (27.8) 83 (32.9) 6 (16.7)
114 g/day
of tobacco
53 (13.1) 92 (14.6) 38 (13.4) 10 (8.7) 10 (21.3) 34 (10.7) 70 (15.1) 6 (7.5) 30 (16.9) 101 (14.6) 18 (9.4) 82 (14.4) 24 (9.5) 5 (13.9)
$15 g/day of
tobacco
140 (34.7) 74 (11.7) 24 (8.5) 11 (9.6) 3 (6.4) 41 (12.9) 38 (8.2) 7 (8.8) 22 (12.4) 76 (11.0) 12 (6.2) 63 (11.0) 22 (8.7) 1 (2.8)
Years of education 0.02 0.006 0.10 0.53
<8 133 (32.6) 26 (4.1) 8 (2.8) 1 (0.8) 2 (4.0) 11 (3.4) 10 (2.1) 9 (10.7) 5 (2.8) 23 (3.3) 6 (3.0) 19 (3.3) 8 (3.1) 2 (5.0)
810 144 (35.3) 147 (23.0) 43 (15.0) 27 (22.1) 6 (12.0) 64 (19.8) 88 (18.6) 19 (22.6) 44 (24.7) 147 (20.9) 28 (13.9) 116 (20.1) 52 (19.8) 4 (10.0)
>10 131 (32.1) 467 (73.0) 235 (82.2) 94 (77.0) 42 (84.0) 248 (76.8) 376 (79.3) 56 (66.7) 129 (72.5) 534 (75.9) 167 (83.1) 441 (76.6) 202 (77.1) 34 (85.0)
Alcohol consumption 0.59 0.08 0.003 0.81
Never 125 (30.5) 105 (16.4) 38 (13.3) 16 (13.1) 10 (20.0) 40 (12.4) 67 (14.1) 19 (22.6) 42 (23.7) 104 (14.8) 19 (9.5) 79 (13.7) 42 (16.0) 4 (10.0)
114/121
drinks/week
223 (54.4) 434 (67.9) 203 (71.0) 91 (74.6) 31 (62.0) 229 (70.9) 346 (73.0) 51 (60.7) 107 (60.5) 491 (69.7) 153 (76.1) 414 (71.9) 182 (69.5) 29 (72.5)
>14/>21
drinks/week
62 (15.1) 100 (15.6) 45 (15.7) 15 (12.3) 9 (18.0) 54 (16.7) 61 (12.9) 14 (16.7) 28 (15.8) 109 (15.5) 29 (14.4) 83 (14.4) 38 (14.5) 7 (17.5)
Body mass index,
kg/m
2
27.5 5.5 24.3 3.3 23.7 2.9 24.3 2.9 24.3 3.0 0.05 24.1 3.2 24.0 3.1 24.0 2.8 0.85 24.8 3.7 24.2 3.2 23.5 2.3 <0.001 24.1 3.2 24.1 2.9 23.2 1.7 0.22
Systolic blood pressure,
mm Hg
139.2 22.8 124.8 17.5 124.7 18.4 124.4 14.6 127.3 17.0 0.78 124.4 16.6 124.3 17.7 127.4 18.6 0.33 125.0 21.0 124.5 17.1 125.6 14.9 0.75 123.8 17.9 126.7 16.4 123.3 14.5 0.07
Diastolic blood pressure,
mm Hg
78.9 12.3 75.5 10.9 74.6 11.8 75.1 9.9 79.3 12.7 0.06 75.3 11.1 74.9 11.4 76.6 11.4 0.44 75.3 11.7 75.5 11.3 74.8 10.0 0.76 74.8 11.6 76.2 10.5 74.7 11.1 0.26
Use of blood pressure
medication
80 (19.6) 17 (2.7) 10 (3.5) 4 (3.3) 3 (6.0) 0.46 9 (2.8) 14 (3.0) 4 (4.8) 0.59 9 (5.1) 21 (3.0) 2 (1.0) 0.05 16 (2.8) 9 (3.5) 0 (0.0) 0.66
Diabetes mellitus 32 (7.8) 12 (1.9) 4 (1.4) 0 (0.0) 0 (0.0) 0.52 6 (1.9) 9 (1.9) 1 (1.2) >0.99 2 (1.1) 13 (1.8) 1 (0.5) 0.43 14 (2.4) 2 (0.8) 0 (0.0) 0.27
Values are mean SD or n (%).
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between joggers and sedentary nonjoggers feasible,
although there were large differences in mean age
inthesegroups.Theaveragenumberofyearsof
jogging was 10.1. There was no interaction between
sex and either pace (p ¼0.27), quantity (p ¼0.26), or
frequency (p ¼0.25) of jogging.
QUANTITY, FREQUENCY, AND PACE OF JOGGING
AND RISK OF MORTALITY. Figure 1 shows the all-
cause mortality HRs, adjusted for age and sex and
multivariable adjusted for joggers compared with
sedentary nonjoggers.
Jogging from 1 to 2.4 h per week was associated with
the lowest mortality (multivariable HR: 0.29; 95% con-
dence interval [CI]: 0.11 to 0.80). The risk estimates
for the subgroups with greater quantities of jogging
were not signicantly different from those for the
sedentary group; jogging from 2.5 to 4 h per week
yielded an HR of 0.65 (95% CI: 0.20 to 2.07).
The optimal frequency of jogging was 2 to 3 times
per week (HR: 0.32; 95% CI: 0.15 to 0.69) or #1time
per week (HR: 0.29; 95% CI: 0.12 to 0.72). The risk
estimates for jogging >3 times per week were not
statistically different from those for the sedentary
group.
Lower mortality rates were associated with a slow
jogging pace (HR: 0.51; 95% CI: 0.24 to 1.10) and
moderate jogging pace (HR: 0.38; 95% CI: 0.22 to
0.66). Notably, the group of fast-paced joggers had
almostthesameriskofmortalityasthesedentary
nonjoggers (HR: 0.94; 95% CI: 0.40 to 2.18).
FIGURE 1 Jogging Variables
Jogging variable
Quantity of jogging
Adjusted for age and sex
Adjusted for age and sex
Adjusted for age and sex
Adjusted for age, sex, smoking,
alcohol intake, education, and diabetes
Adjusted for age, sex, smoking,
alcohol intake, education, and diabetes
Adjusted for age, sex, smoking,
alcohol intake, education, and diabetes
Sedentary nonjogger (reference)
Sedentary nonjogger (reference)
<1 hour/week
>4 hours/week
1-2.4 hours/week
2.5-4 hours/week
<1 hour/week
>4 hours/week
1-2.4 hours/week
2.5-4 hours/week
Sedentary nonjogger (reference)
≤1 time/week
>3 times/week
2-3 times/week
Sedentary nonjogger (reference)
Sedentary nonjogger (reference)
Sedentary nonjogger (reference)
≤1 time/week
>3 times/week
Slow
Average
Fast
Slow
Average
Fast
2-3 times/week
Frequency of jogging
Jogging pace
No. of
Participants
All-cause mortality
Hazard Ratio
Deaths HR (95% CI) Forest plot
413
640
286
122
50
394
629
282
115
47
413
323
474
84
394
317
80
413
178
704
201
394
692
176
192 6
15
15
7
7
120
128
120
5
5
7
128
5
5
7
120
20
3
1
4
128 1.00
1.00
1.00
1.00
1.00
1.00
0.32 (0.20-0.51)****
0.47 (0.29-0.77)***
0.19 (0.08-0.47)****
0.20 (0.09-0.43)****
0.48 (0.19-1.17)
0.29 (0.12-0.72)***
0.32 (0.15-0.69)***
0.34 (0.16-0.73)***
0.25 (0.14-0.43)****
0.71 (0.29-1.75)
0.54 (0.24-1.26)
0.51 (0.24-1.10)*
0.94 (0.40-2.18)
0.0 0.5 1.0 1.5 2.0 2.5
0.38 (0.22-0.66)****
0.29 (0.11-0.80)**
0.65 (0.20-2.07)
0.60 (0.08-4.36)
0.18 (0.07-0.50)****
0.38 (0.12-1.19)*
0.35 (0.05-2.54)
20
3
1
4
6
463
Quantity, frequency, and pace of jogging in relation to all-cause mortality. HR ¼hazard ratio. *p <0.10; **p <0.05; ***p <0.01; ****p <0.001.
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SURVIVAL IN LIGHT, MODERATE, AND STRENUOUS
JOGGERS. The joggers were divided into 3 groups
(light, moderate, and strenuous joggers), which were
thencomparedwiththesedentarynonjoggersgroup.
The Central Illustration shows that light joggers had
the most favorable fully adjusted HR for all-cause
mortality (0.22; 95% CI: 0.10 to 0.47); the HR for
moderate joggers was 0.66 (95% CI: 0.32 to 1.38) and
for strenuous joggers was 1.97 (95% CI: 0.48 to 8.14).
Comparedwithlightjoggers,themoderateand
strenuous joggers had signicantly higher adjusted
HRs (3.06 [95% CI: 1.11 to 8.45] and 9.08 [95% CI: 1.87
to 44.01], respectively). These ndings suggest that
there is a U-shaped association between jogging and
mortality.
CAUSES OF DEATHS AMONG JOGGERS AND
SEDENTARY NONJOGGERS. The small number of
deaths in each group made it impossible to report
different causes of deaths, but we previously pre-
sented cause-specic mortality among 1,878 joggers
and 16,423 nonjoggers followed up for a maximum of
35 years (16). The adjusted HRs for CHD were 0.32
for men (95% CI: 0.15 to 0.67) and 0.48 for women
(95% CI: 0.12 to 1.96), for respiratory diseases were
0.85 for men (95% CI: 0.39 to 1.83) and 0.87 for
women (95% CI: 0.27 to 2.84), for stroke were 0.95
for men (95% CI: 0.42 to 2.18) and 0.85 for women
(95% CI: 0.21 to 3.42), and for cancer were 0.82
for men (95% CI: 0.58 to 1.16) and 0.68 for women
(95% CI: 0.38 to 1.23).
DISCUSSION
In this prospective, observational study, which
included 1,098 healthy joggers between 20 and
86 years of age who were followed up for 12 years,
we compared the long-term all-cause mortality rates
of light, moderate, and strenuous joggers with the
long-term mortality rate of sedentary nonjoggers. We
found a U-shaped association between jogging and
mortality. The lowest mortality was among light
joggers in relation to pace, quantity, and frequency
of jogging. Moderate joggers had a signicantly
higher mortality rate compared with light joggers, but
it was still lower than that of sedentary nonjoggers,
whereas strenuous joggers had a mortality rate that
was not statistically different from that of sedentary
nonjoggers (Central Illustration).
It should be emphasized that even slow jogging
(6 METs) corresponds to vigorous exercise and stren-
uous jogging corresponds to very heavy vigorous
exercise ($12 METs), which when performed for
decades could pose health risks, especially to the CV
system.
A recently published study of 55,000 adults be-
tween 18 and 100 years of age who were followed
up for a mean of 15 years, using comprehensive
analyses that controlled for potential confounding
factors, reported that runners as compared with
nonrunners had 30% and 45% lower risks of all-
cause and CV mortality, respectively, with a mean
improvement in life expectancy of 3 years (21).
CENTRAL ILLUSTRATION Dose of Jogging and Long-Term Mortality
Adjusted for age and sex
0.0 0.5 1.5 2.0 2.51.0
DOSE OF JOGGING
NO. OF
PARTICIPANTS
ALL-CAUSE MORTALITY
DEATHS FOREST PLOT
Hazard Ratio
413
576
262
40
128
7
8
2
394
570
252
36
120
7
8
2
Sedentary nonjogger (reference)
Light jogger
Moderate jogger
Strenuous jogger
Adjusted for age, sex, smoking,
alcohol intake, education, and diabetes
Sedentary nonjogger (reference)
Light jogger
Moderate jogger
Strenuous jogger
3.67
8.14
Schnohr, P. et al. J Am Coll Cardiol. 2015; 65(5):411–9.
Forest plot indicating all-cause mortality in light, moderate, and strenuous joggers compared with sedentary nonjoggers.
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Again, however, maximal CV longevity benets were
noted with moderate doses of running (specically
6 to 12 miles per week), running durations of
approximately 50 to 120 min per week, a running
frequency of approximately 3 times per week, and a
modest pace of approximately 6 to 7 miles per hour.
Our ndings are aligned in that a U-shaped or
reverse J-shaped relationship was noted, whereas
higher doses of running were associated with loss of
approximately one-third to one-half of the CV mor-
tality benets linked to moderate doses of running.
In fact, the most favorable running regimen for
reducing CV mortality in that study was 6 miles per
week, 3 running days per week, and a pace of 7 miles
per hour.
Other studies that did not focus solely on joggers
but instead on cumulative doses of exercise have
also reported U-shaped or reverse J-shaped curves
depicting the relationship between leisure-time
physical activity and mortality (2224).Anumber
of large studies have found an inverse associa-
tion between physical activity in leisure time and
morbidity/mortality from CHD and all-cause mor-
tality (46,2533).However,eventherst such
landmark study by Paffenbarger et al. (22) found
that death rates declined steadily as energy expen-
ded on physical activity increased from <500 kcal
per week to 3,500 kcal per week, beyond which
mortality rates increased again. A weekly energy
expenditure of 3,500 kcal is approximately equiva-
lent to that required for running 35 miles, which is
in the range of the upper limits for incremental
health benets from strenuous exercise identied by
several recent large epidemiological reports (3437).
These studies found that a weekly cumulative dose
of approximately 30 miles of running or 46 miles of
walking is approximately the safe upper limit for
optimizing long-term CV health and life expectancy
(3437).
Over the past 35 years, the number of Americans
who jog has risen 20-fold. In 2013, the number
of U.S. joggers was estimated to be 54 million. The
number of marathon nishers has risen from 25,000
in 1976 to 541,000 in 2013, and approximately
1,960,000 people completed a half-marathon in
2013 (38). The incidence of sudden cardiac death
in these endurance races was very low in absolute
numbers, although the rate was signicantly higher
(almost 4-fold) in marathons (1.01 per 100,000; 95%
CI: 0.72 to 1.38) than in half-marathons (0.27;
95% CI: 0.17 to 0.43) (14). Triathlons, which can
involve even higher doses of strenuous exercise
than marathons, also have been growing rapidly in
popularity. In 1999, there were 127,824 members
of USA Triathlon; this number grew to 510,859 in
2012 (39).
Long-term strenuous endurance exercise may
induce pathological structural remodeling of the
heart and large arteries. Emerging data suggest that
long-term training for and competing in extreme en-
durance events such as marathons, ultra-marathons,
ironman distance triathlons, and very long distance
bicycle races can cause transient acute volume over-
load of the atria and right ventricle, with transient
reductions in right ventricular ejection fraction and
elevation of cardiac biomarker levels (40).Monthsto
years of repetitive injury in some people may lead to
patchy myocardial brosis, particularly in the atria,
interventricular septum, and right ventricle, creating
a substrate for atrial and ventricular arrhythmias (41).
Additionally, long-term excessive exercise may be
associated with coronary artery calcication, diastolic
dysfunction, and large artery wall stiffening (42).
To our knowledge, there has been no study of the
longevity of marathon, half-marathon, or triathlon
participants, but such studies would clearly be
informative.
Higher doses of running are associated with
progressively better cardiorespiratory tness as
well as dose-dependent improvements in many CV
risk factors, such as abdominal adiposity, glucose
metabolism, and high-density lipoprotein choles-
terol level, along with preservation of youthful
levels of left ventricular compliance (43). Even so,
accumulating evidence suggests that activity pat-
terns that are ideal for promoting long-term CV
health and enhancing life expectancy may differ
from the high-intensity, high-volume endurance
training regimens used for developing peak car-
diac performance and maximum cardiorespiratory
tness (44).
STUDY LIMITATIONS. The strengths include the ran-
dom population sample, prospective design, detailed
information about potential confounding variables,
and almost 100% complete follow-up. The limitations
include the fact that the information about jogging
used in the present analyses was solely obtained
at the fourth examination (between 2001 and 2003);
repeated assessments of jogging during follow-up
wouldhavestrengthenedthedesign.Evenso,pre-
vious analyses suggest that jogging seems to be
a fairly stable habit among Copenhagen residents
(16). However, because our study was observational
and not randomized, we can only show associations
and not casual relationships. Through exclusion
of all participants who had CHD, stroke, or DM,
we partly ruled out a self-selection bias against
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jogging among sick subjects. Furthermore, we
repeated the analyses after excluding all deaths
within the rst 2 years of follow-up and found
similar results.
CONCLUSIONS
Our results, which were obtained by using a large
random sample of men and women, showed that
although joggers as a group appear to live longer than
sedentary nonjoggers, light joggers and moderate
joggers have lower mortality rates than sedentary
nonjoggers, whereas strenuous joggers have a mor-
tality rate that is not statistically different from that
of the sedentary group. The U-shaped association
suggests the existence of an upper limit for exercise
dosing that is optimal for health benets. This
hypothesis should be investigated further and, if
conrmed, may eventually need to be incorporated
into healthy physical activity guidelines for the
general public.
On the basis of current knowledge, if the goal is
to decrease the risk of death and improve life ex-
pectancy, going for a leisurely jog a few times per
week at a moderate pace is a good strategy. Higher
doses of running are not only unnecessary but may
also erode some of the remarkable longevity bene-
ts conferred by lower doses of running. In this
study, the dose of running that was most favorable
for reducing mortality was jogging 1 to 2.4 h per
week, with no more than 3 running days per week,
at a slow or average pace. Many adults will perceive
this to be a goal that is practical, achievable, and
sustainable.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Peter Schnohr, Copenhagen City Heart Study, Fred-
eriksberg Hospital, Nordre Fasanvej 57, Copenhagen
DK-2000, Denmark. E-mail: peter@schnohr.dk.
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PERSPECTIVES
COMPETENCY IN MEDICAL KNOWLEDGE:
Compared with more sedentary people, people who
jog regularly exhibit a signicantly lower all-cause
mortality rate. Those who jog lightly or moderately
appear to benet more than strenuous joggers, whose
long-term mortality rate is similar to that of sedentary
people.
COMPETENCY IN PATIENT CARE: When pre-
scribing exercise to improve longevity, strenuous
exercise is not necessary and might reduce the health
benets of light to moderate physical activity.
TRANSLATIONAL OUTLOOK: Further studies are
needed to explore the mechanisms by which exces-
sively strenuous exercise adversely affects longevity
before the pattern of association between exercise
intensity and long-term mortality can be incorporated
into physical activity recommendations for the
general public.
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KEY WORDS all-cause mortality,
Copenhagen City Heart Study, jogging,
physical activity
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Background Post-industrial societies that benefit from the development of science, technology and subsequent inventions that relieve people of everyday duties, on the one hand, have more free time, but on the other hand face a greater temptation of laziness and lack of physical activity. Common diseases increasingly resulting from limited physical activity (PA) mean that physical activity is no longer just a way to spend free time, but a necessity in the field of health care. This necessity obliges us to undertake research that allows for recognizing factors influencing the level of physical activity in individual societies. Objective The conducted research aimed at identifying sociodemographic factors that would determine the level of physical activity in women and men from the Biała Podlaska district in eastern Poland. Participants The group consisted of 173 adults, including 71 women and 102 men from eastern Poland. Methods The presented research was conducted in the years 2018–2020 as part of the international EUPASMOS Plus project. The collected sociodemographic data of the respondents and the results of physical activity monitoring with the use of the GPAQ questionnaire and the RM42 accelerometer − 24/7 allowed for an analysis of the factors determining the physical activity undertaken by the respondents, as well as the comparison of the obtained data with the use of the above-mentioned tools. Results The results of the research on sociodemographic factors conditioning the physical activity of the examined persons, obtained from the objective tool (Acceleromete RM42) and a subjective one for measuring physical activity (GPAQ questionnaire) showed some discrepancies. However, the established consistency of the research results using the above-mentioned tools allows for formulating the following conclusions: women from the Biała Podlaska district are more active than men. Older people more often undertake PA of lower intensity, giving up high-intensity efforts. The respondents declaring a higher subjective assessment of their health are more physically active. Conclusions The results obtained are varied and depend on the used tool. They indicate an enormous importance of the tool used in the study on physical activity.
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In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health. The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations. The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health. Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists. This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995. Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues. Key points related to updating the physical activity recommendation were outlined and writing groups were formed. A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts. Comments were integrated into the final recommendation. Primary recommendation: To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week. [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days. Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes. [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate. In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week. [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity. [I (A)]