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Lack of leisure time physical activity and variations in cardiovascular mortality across US communities: a comprehensive county-level analysis (2011–2019)
  1. Shady Abohashem1,2,
  2. Khurram Nasir3,
  3. Malak Munir4,
  4. Ahmed Sayed4,
  5. Wesam Aldosoky1,
  6. Taimur Abbasi1,
  7. Erin D Michos5,
  8. Martha Gulati6,
  9. Jamal S Rana7
  1. 1 Cardiovascular Research Center and Cardiology Division, Massachusetts General Hospital - Harvard Medical School, Boston, Massachusetts, USA
  2. 2 Epidemiology Department, Harvard University T. H. Chan School of Public Health, Boston, Massachusetts, USA
  3. 3 Department of Cardiology Houston Methodist DeBakey Heart, Vascular Center, Houston, Texas, USA
  4. 4 Department of Medicine, Ain Shams University, Cairo, Egypt
  5. 5 Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  6. 6 Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
  7. 7 Department of Cardiology and Division of Research, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
  1. Correspondence to Dr Shady Abohashem, Cardiovascular Research Center-Cardiology Department, Massachusetts General Hospital - Harvard Medical School, Epidemiology Department - Harvard School of Public Health, Boston, Massachusetts, USA; Sabohashem{at}; Shady.Abohashem{at}


Objectives To investigate the associations between county-level proportions of adults not engaging in leisure-time physical activity (no LTPA) and age-adjusted cardiovascular mortality (AACVM) rates in the overall US population and across demographics.

Methods Analysing 2900 US counties from 2011 to 2019, we used the Centers for Disease Control and Prevention (CDC) databases to obtain annual AACVM rates. No LTPA data were sourced from the CDC’s Behavioural Risk Factor Surveillance System survey and county-specific rates were calculated using a validated multilevel regression and poststratification modelling approach. Multiple regression models assessed associations with county characteristics such as socioeconomic, environmental, clinical and healthcare access factors. Poisson generalised linear mixed models were employed to calculate incidence rate ratios (IRR) and additional yearly deaths (AYD) per 100 000 persons.

Results Of 309.9 million residents in 2900 counties in 2011, 7.38 million (2.4%) cardiovascular deaths occurred by 2019. County attributes such as socioeconomic, environmental and clinical factors accounted for up to 65% (adjusted R2=0.65) of variance in no LTPA rates. No LTPA rates associated with higher AACVM across demographics, notably among middle-aged adults (standardised IRR: 1.06; 95% CI (1.04 to 1.07)), particularly women (1.09; 95% CI (1.07 to 1.12)). The highest AYDs were among elderly non-Hispanic black individuals (AYD=68/100 000).

Conclusions Our study reveals a robust association between the high prevalence of no LTPA and elevated AACVM rates beyond other social determinants. The most at-risk groups were middle-aged women and elderly non-Hispanic black individuals. Further, county-level characteristics accounted for substantial variance in community LTPA rates. These results emphasise the need for targeted public health measures to boost physical activity, especially in high-risk communities, to reduce AACVM.

  • Cardiovascular Diseases
  • Physical activity
  • Preventive Medicine
  • Public health
  • Women

Data availability statement

Data are available from public resources that can be accessed online (see appendix). The study included publicly available data from online resources. Links to referred resources are provided in the study appendix.

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Data availability statement

Data are available from public resources that can be accessed online (see appendix). The study included publicly available data from online resources. Links to referred resources are provided in the study appendix.

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  • Contributors SA conceived and designed the study, had full access to all data, and took responsibility for study analysis and data integrity. Concept, supervision, and study guarantor: SA. Acquisition, analysis, and data interpretation: SA, MM, and JSR. Statistical analysis: SA, WA, and AS. Administrative, technical, or material support: SA, MM. Drafting of the manuscript: SA. Critical revision and approval of the final manuscript: All authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer MG served on an advisory board for Novartis and Esperion. She is a co-investigator and site PI of the Women's IschemiA TRial to Reduce Events In Non-ObstRuctive CAD (WARRIOR) Study funded by the Department of Defense (Award Number: W81XWH-17-2-0030). None of the remaining authors have conflicts of interest pertinent to the contents of this manuscript.

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  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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