Association of Daily Step Counts With All-Cause Mortality and Cardiovascular Events

What is the least number of steps required per day to get a cardiovascular benefit?

We have all heard that people should take 10,000 steps per day as this will help reduce cardiovascular (CV) disease and mortality. However, often, this number sounds too high. Hence, what is the minimum number of steps that a person can take in a day and still get benefits? If the number of steps is reasonable, we could get more of our patients walking.

This study examined the data from 111,309 people from 12 studies evaluating the association of step counts and CV event rates. The authors used 2000 steps per day as the baseline comparator. They found that, with 2517 steps per day, there was an 8.0% statistical reduction in all-cause mortality (aHR, 0.92; 95% CI, 0.84–0.999) and, with 2735 steps per day, there was an 11% — statistically significant — reduction in CV events. Therefore, with just 500 to 700 extra steps, there is a measurable reduction in mortality and CV events. Now, even to the most sedentary person that sounds very doable.

There was a dose–response curve, so the more steps taken, the better the reductions in CV events. At 8763 steps per day, there was a 60% reduction in mortality (aHR, 0.40; 95% CI, 0.38–.43). However, with more than 8763 steps, there is still a reduction in mortality, but it is no longer statistically significant. For CV events, 7126 steps per day led to a 51% reduction (aHR, 0.49; 95% CI, 0.45–0.55), and, with more steps, the reduction increased but was no longer statistically significant. Now, this could mean that more steps were no longer useful or that, in these studies, there were fewer and fewer people who took that many steps, and hence, there were not enough people to be able to see a statistical benefit.

When the researchers looked at cadence (the number of steps taken per minute), the higher the cadence the better the benefit.

Sensors worn on the hips had the best correlation to event reductions. This might be because the hip-worn sensors truly measured your steps, whereas the wrist-worn sensors could just be measuring arm movement.

This study did not tell us whether the steps accumulated all day or whether they were taken in dedicated time frames. That would be of great interest because nowadays experts say that sitting for extended periods of time and not moving is the real culprit. So perhaps steps spread throughout the day might be better than all the steps compressed into 1 hour. 

If the steps are spread out, then the leg muscles are constantly turned on, which means that the blood vessels are constantly dilated to supply blood flow to the muscles. Dilated vessels mean less pressure, and the heart has an easier time to pump because there is less resistance. Perhaps future studies can look at how the steps are spread throughout the day to determine whether there is a difference associated with the timing of walking.

For now, our advice to our patients will be music to their ears: No longer do you have to hit 10,000 steps per day – just take at least 2700 steps per day and you will get some benefit with regard to death and CV events. However, if you can take more, then you will be rewarded with even fewer events and increased longevity. Not a bad sales pitch.

Taking the right steps for health

Measuring step counts using pedometers and accelerometers is a more accurate way to assess physical activity and avoids the biases associated with self-reporting. My colleagues and I searched available electronic databases to identify 12 studies (111,309 participants) that objectively measured physical activity and reported health outcomes.¹ 

Compared with the reference level of 2000 steps per day (steps/d), an increase of only 517 steps was associated with an 8% reduction in total mortality (95% CI, −1% to −16%). Similarly, compared with 2000 steps/d, an increase of 735 steps was associated with an 11% reduction in cardiovascular disease events (CVD; 95% CI, −1% to −21%). The steepest decline in mortality and CVD benefits occurred at low levels of physical activity. More steps/d were associated with a more gradual reduction in deaths and CVD events up to maximal reduction at 8763 steps/day (−60%; CI, −57% to −62%) for deaths and a maximal reduction at 7126 steps/d.(−51%; CI, −45% to – 55%) for  CVD events. Results did not differ by sex, but faster stepping rates were associated with lower mortality. (I had a colleague who said you could tell how long a patient would live by how quickly he/she walked into the examining room.) Risk reductions were more pronounced with hip-worn accelerometers than with pedometers or wrist-worn devices possibly because the hip accelerometers were a better measure of steps. 

This manuscript adds to the plethora of studies showing that even small levels of physical activity are associated with health benefits. It also provides measurement accuracy to the often-recommended 10,000 steps/d and provides a ceiling of benefit close to that recommended level. Such studies should remind clinicians to ask about and talk about physical activity. The ask? “What are you doing for physical activity?”  Avoid asking about “exercise” because many patients think that means gym-type activities. The talk? “You should try to walk as much as possible. Every little walk helps, and you get maximal benefit at around 10,000 steps/d.” Such simple questions and instructions can help patients take the right steps (and number of steps) toward better health. 

Reference

1. Stens NA, Bakker EA, Mañas A, et al. Relationship of Daily Step Counts to All-Cause Mortality and Cardiovascular Events. Am Coll Cardiol. 2023 Oct 10;82(15):1483-1494. https://www.sciencedirect.com/science/article/abs/pii/S0735109723064008?via%3Dihub