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Original Investigation
July 5, 2022

Association of the “Weekend Warrior” and Other Leisure-time Physical Activity Patterns With All-Cause and Cause-Specific Mortality: A Nationwide Cohort Study

Author Affiliations
  • 1Department of Preventive Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
  • 2Escuela de Ciencias de la Actividad Física, el Deporte y la Salud, Universidad de Santiago de Chile, Santiago, Chile
  • 3Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 4Faculty of Health Sciences, Valencian International University, Valencia, Spain
  • 5Faculty of Sport, Catholic University of Murcia, Murcia, Spain
  • 6Department of Nutrition, Bjørknes University College, Oslo, Norway
  • 7Department of Endocrinology, Morbid Obesity, and Preventive Medicine, Oslo University Hospital, Oslo, Norway
  • 8Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
  • 9Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
  • 10School of Nursing, Guangdong Pharmaceutical University, Haizhu District, Guangzhou, China
  • 11Department of Sociology and Institute for Empirical Social Science Research, School of Humanities and Social Sciences, Xi’an Jiaotong University, Xi’an, China
  • 12Public Health Research Center and Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi, Jiangsu, China
  • 13Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
JAMA Intern Med. 2022;182(8):840-848. doi:10.1001/jamainternmed.2022.2488
Key Points

Question  Does performing the recommended levels of weekly physical activity in 1 to 2 sessions (weekend warrior) vs 3 or more sessions (regularly active) influence mortality?

Findings  This large prospective cohort study of 350 978 adults in the US did not find any significant difference in mortality rates between weekend warriors and regularly active participants. Compared with physically inactive participants, active participants (both weekend warrior and regularly active) had lower all-cause and cause-specific mortality rates.

Meaning  Adults who perform 150 minutes or more of moderate to vigorous physical activity (or 75 minutes of vigorous activity) per week may experience similar health benefits whether the sessions are spread throughout the week or concentrated in a weekend.

Abstract

Importance  It is unclear whether the weekly recommended amount of moderate to vigorous physical activity (MVPA) has the same benefits for mortality risk when activity sessions are spread throughout the week vs concentrated in fewer days.

Objective  To examine the association of weekend warrior and other patterns of leisure-time physical activity with all-cause and cause-specific mortality.

Design, Setting, and Participants  This large nationwide prospective cohort study included 350 978 adults who self-reported physical activity to the US National Health Interview Survey from 1997 to 2013. Participant data were linked to the National Death Index through December 31, 2015.

Exposures  Participants were grouped by self-reported activity level: physically inactive (<150 minutes per week [min/wk] of MVPA) or physically active (≥150 min/wk of moderate or ≥75 min/wk of vigorous activity). The active group was further classified by pattern: weekend warrior (1-2 sessions/wk) or regularly active (≥3 session/wk); and then, by frequency, duration/session, and intensity of activity.

Main Outcomes and Measures  All-cause, cardiovascular disease (CVD), and cancer mortality. Statistical analyses were performed in April 2022.

Results  A total of 350 978 participants (mean [SD] age, 41.4 [15.2] years; 192 432 [50.8%] women; 209 432 [67.8%] Non-Hispanic White) were followed during a median of 10.4 years (3.6 million person-years). There were 21 898 deaths documented, including 4130 from CVD and 6034 from cancer. Compared with physically inactive participants, hazard ratios (HR) for all-cause mortality were 0.92 (95% CI, 0.83-1.02) for weekend warrior and 0.85 (95% CI, 0.83-0.88) for regularly active participants; findings for cause-specific mortality were similar. Given the same amount of total MVPA, weekend warrior participants had similar all-cause and cause-specific mortality rates as regularly active participants. The HRs for weekend warrior vs regularly active participants were 1.08 (95% CI, 0.97-1.20) for all-cause mortality; 1.14 (95% CI, 0.85-1.53) for CVD mortality; and 1.07 (95% CI, 0.87-1.31) for cancer mortality.

Conclusions and Relevance  The findings of this large prospective cohort study suggest that individuals who engage in active patterns of physical activity, whether weekend warrior or regularly active, experience lower all-cause and cause-specific mortality rates than inactive individuals. Significant differences were not observed for all-cause or cause-specific mortality between weekend warriors and regularly active participants after accounting for total amount of MVPA; therefore, individuals who engage in the recommended levels of physical activity may experience the same benefit whether the sessions are performed throughout the week or concentrated into fewer days.

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    3 Comments for this article
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    Statistical questions about the study
    Marco Huesch, MBBS, PhD | N/a
    This study raises several questions.

    First, there are 50 or so comparisons being made. Adjustment for multiple comparisons would broaden confidence intervals and render some point estimates insignificant.

    Second, some key point estimates (for example, the mortality of weekend warriors as compared to physically inactive participants) already have broad confidence intervals for the hazard ratio that include 1.

    Third, other key results (see Tables 4 and 5) have no significant hazard ratios. This doesn’t mean that there is no difference between, for example, a low or high intensity or frequency of exercise compared to regular activities. It
    means that the respective hazard ratios could fall below 1 or above 1, but either the study wasn’t powered to detect that or there was no consistent difference.
    CONFLICT OF INTEREST: None Reported
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    Suggestion of taking sleep into consideration in covariate analysis
    Kun Huang, M.D. candidate | Beijing Children's Hospital, Capital Medical University
    With great interest, we read the recently published paper by Dr. Mauricio and his colleagues.1 This large cohort study revealed the benefits of reduced all-cause mortality of regular physical activity, no matter in a “weekend warrior” or “leisure-time” mode. They also confirmed the lack of significant difference for all-cause or cause-specific mortality between the two modes. Although the advantages of regular physical activity have been fully investigated and become a common sense, this paper is very interesting and makes novel comparison between two different physical activity modes. The results encourage people to take exercise regularly with any of their preferred activity mode to obtain benefits, which will be very meaningful for education or policy setting in public health.

    In the covariates analysis, the authors included many factors which could potentially influence the results, like educational attainment, income level and psychological distress. In lifestyle behaviors, smoking status and alcohol consumption were included. However, as a very important influence factor, the evaluation of sleep was not considered in their analysis. Although the effect of sleep on health is quite complex, various studies have confirmed the close connection between them. Previous study has demonstrated a curvilinear (U-shaped) relationship between sleep duration and all-cause mortality and suggested a 7-8 hour of sleep time accordingly.2 Other factors like sleep quality and timing have also been recognized as inter-related dimensions of health sleep characteristics and should be taken into consideration during the evaluation of sleep. As previously reported, poor sleep quality together with inadequate or excess sleep could lead to a higher mortality risk.3,4 In addition to independent health effects, joint effects of sleep and other influence factors have also been investigated. According to Huang et al, low physical activity might exacerbate the detrimental relationship between sleep and all-cause/cause-specific mortality.5

    Considering a large amount of time that we spend on sleep, together with the above-mentioned close correlations between sleep and health outcome (including mortality risk), we suggest the authors to take sleep into covariates analysis. The integration of sleep evaluation could potentially improve this study, or they might also consider taking it in future studies.

    Reference
    1. Liao B, Huang W, Nie J, Wang Y, Giovannucci E. Association of the “Weekend Warrior” and Other Leisure-time Physical Activity Patterns With All-Cause and Cause-Specific Mortality A Nationwide Cohort Study. JAMA Intern Med. 2022;Jul 5. doi:10.1001/jamainternmed.2022.2488
    2. Kwok CS, Kontopantelis E, Kuligowski G, et al. Self-reported sleep duration and quality and cardiovascular disease and mortality: A dose-response meta-analysis. J Am Heart Assoc. 2018;7(15):1-26. doi:10.1161/JAHA.118.008552
    3. Chien KL, Chen PC, Hsu HC, et al. Habitual sleep duration and insomnia and the risk of cardiovascular events and all-cause death: Report from a community-based cohort. Sleep. 2010;33(2):177-184. doi:10.1093/sleep/33.2.177
    4. Rod NH, Kumari M, Lange T, Kivimäki M, Shipley M, Ferrie J. The joint effect of sleep duration and disturbed sleep on cause-specific mortality: Results from the Whitehall II cohort study. PLoS One. 2014;9(4). doi:10.1371/journal.pone.0091965
    5. Huang BH, Duncan MJ, Cistulli PA, Nassar N, Hamer M, Stamatakis E. Sleep and physical activity in relation to all-cause, cardiovascular disease and cancer mortality risk. Br J Sports Med. 2022;
    CONFLICT OF INTEREST: None Reported
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    Health Benefits in Weekend Warriors ?
    Lars Brechtel, MD, Prof. Dr. med. | Exercise and Sports Medicine, Institute of Translational Medicine for Health Care Systems, MSB Medical School Berlin, Berlin, Germany
    The published paper by dos Santos et al.1 addressed an open question in the field of exercise medicine. Performance capacity, health benefits and risks are related to the kind of sports, pattern, duration, intensity and training years. Although inter-variability of the dose-response relationship and familiar aggregation of responses might influence the outcome2.

    The study contains several statistical weakness resulting in an over-interpretation of some results. For example, when comparing the physical inactive vs the weekend warrior group, often the hazard ratios includes the 1.0, which means, that there is no effect. Second, multiple statistical testing requires adjustment of the
    significance level, which was not carried out by the authors.

    The authors mentioned that there was only a small amount of deaths in the weekend warrior group, but didn’t take into account, that they contributed only to 3 % of the total study cohort. Large differences in case numbers may have a great impact on the results by enhancing the death rates by few additional deaths. Therefore a weighting factor to adjust the different sample sizes is missed. Interestingly the relative deaths rates are lying between the physical inactive and moderate physical activity groups.

    There are some limitations which are not raised by the authors. One issue, that the authors aren’t able to solve by the used NHIS data, is the physical activity categorization reported by the participants. At least sweating and heart rate regulation show a high inter-individual variability and are changed by intra-individual adaptations throughout trainings programs. For example, heavy sweating does not always mean, that a high exercise intensity was applied, but might represent an optimized thermoregulation. Additionally these physiological signs are depending on external factors like weather conditions, cooling by wind, fluid availability, etc.

    Many sports include a mixture of standing, light, moderate and vigorous components (e.g. ball games, top-and-go sports), but participants often rated the overall session by the highest intensity level, their exertion or exhaustion. Additionally different exercises address different physiological (sub-) systems like endurance, strength or coordination, which might result in different health outcomes. Especially the latter should be taken into account in future studies by established classification methods3,4. Although seasonal pattern of physical activity couldn’t be considered, the authors missed the chance to analyze pattern changes throughout life. From a public health and economic standpoint also health risks like possible higher injury rates in weekend warriors should be addressed.

    Reference
    1. Dos Santos M, Ferrari G, Lee DH, et al. Association of the "Weekend Warrior" and Other Leisure-time Physical Activity Patterns With All-Cause and Cause-Specific Mortality: A Nationwide Cohort Study. JAMA Intern Med. 2022;182(8):840-488. doi:10.1001/jamainternmed.2022.2488
    2. Sarzynski MA, Rice TK, Després JP, et al. The HERITAGE Family Study: A Review of the Effects of Exercise Training on Cardiometabolic Health, with Insights into Molecular Transducers. Med Sci Sports Exerc. 2022;54(5S): S1-S43. doi:10.1249/MSS.0000000000002859
    3. Ainsworth BE, Haskell WL, Herrmann SD, et al. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;43(8):1575-81. doi:10.1249/MSS.0b013e31821ece12
    4. Mitchell JH, Haskell W, Snell P, VanCamp SP. Task Force 8: classification of sports. J Am Coll Cardiol. 2005;45(8):1364-7.
    CONFLICT OF INTEREST: None Reported
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