Joint associations of leisure-time physical activity and daily sitting time with mortality among US adults classified as CKM stages 0–3: a prospective cohort study of NHANES 2007–2018
Abstract
Background: Prior studies have linked physical activity to cardiovascular-kidney-metabolic (CKM) prevalence or mortality and sedentary behavior to CKM severity, and both behaviors are established mortality risk factors in the general population; however, prospective evidence on their joint associations with cause-specific mortality across CKM stages 0–3 remains limited.
Methods: We analyzed 8,556 NHANES 2007–2018 participants aged ≥20 years with CKM stages 0–3, complete prespecified covariates, and a positive fasting-subsample weight. Leisure-time physical activity (LTPA) was categorized as inactive (0 min/week), insufficient (>0 to <150 min/week), or sufficient (≥150 min/week); daily sitting time was categorized as <6, 6 to <8, or ≥8 h/day. The primary outcome was all-cause mortality; cardiovascular disease (CVD) and non-CVD mortality were secondary outcomes. Survey-design-based Cox models incorporated the 12-year fasting weight, strata, and primary sampling units. Multiplicative and additive interactions were assessed.
Results: During a median follow-up of 6.75 years, 670 deaths occurred, including 175 CVD and 495 non-CVD deaths. In fully adjusted models, sufficient versus no LTPA was associated with lower all-cause (hazard ratio [HR], 0.630; 95% confidence interval [CI], 0.483–0.822), CVD (HR, 0.536; 95% CI, 0.297–0.969), and non-CVD mortality (HR, 0.662; 95% CI, 0.478–0.916). Sitting ≥8 versus <6 h/day was associated with higher all-cause (HR, 1.506; 95% CI, 1.253–1.810), CVD (HR, 1.845; 95% CI, 1.246–2.732), and non-CVD mortality (HR, 1.406; 95% CI, 1.109–1.782). Compared with sufficient LTPA and sitting <6 h/day, <150 min/week of LTPA combined with sitting ≥8 h/day was associated with all-cause (HR, 1.972; 95% CI, 1.429–2.721), CVD (HR, 2.493; 95% CI, 1.232–5.045), and non-CVD mortality (HR, 1.806; 95% CI, 1.202–2.712). Multiplicative interaction was not detected for all-cause (P = 0.951) or non-CVD mortality (P = 0.274); the CVD interaction signal (P = 0.016) was exploratory because it depended on a joint category with few events.
Conclusion: Higher LTPA and shorter sitting time were independently associated with lower mortality among US adults with CKM stages 0–3. Joint categories identified a higher-risk behavioral pattern, but did not establish that LTPA offsets the risk of prolonged sitting.
Supplementary information: The online version contains supplementary material available at https://doi.org/10.1265/ehpm.26-00088.
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BibTeX
@article{xu2026joint,
title = {{Joint associations of leisure-time physical activity and daily sitting time with mortality among US adults classified as CKM stages 0–3: a prospective cohort study of NHANES 2007–2018}},
author = {Sufang Xu and Jiaming Huang and Lingrong Hu and Xiaoming Li and Shumin Zhao and Kaihong Chen and Liling Chen},
journal = {Environmental Health and Preventive Medicine},
year = {2026},
month = oct,
doi = {10.1265/ehpm.26-00088},
url = {https://www.jstage.jst.go.jp/article/ehpm/31/0/31_26-00088/_article},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Joint associations of leisure-time physical activity and daily sitting time with mortality among US adults classified as CKM stages 0–3: a prospective cohort study of NHANES 2007–2018
AU - Sufang Xu
AU - Jiaming Huang
AU - Lingrong Hu
AU - Xiaoming Li
AU - Shumin Zhao
AU - Kaihong Chen
AU - Liling Chen
PY - 2026
DA - 2026/10/20
JO - Environmental Health and Preventive Medicine
DO - 10.1265/ehpm.26-00088
UR - https://www.jstage.jst.go.jp/article/ehpm/31/0/31_26-00088/_article
AB - Background: Prior studies have linked physical activity to cardiovascular-kidney-metabolic (CKM) prevalence or mortality and sedentary behavior to CKM severity, and both behaviors are established mortality risk factors in the general population; however, prospective evidence on their joint associations with cause-specific mortality across CKM stages 0–3 remains limited. Methods: We analyzed 8,556 NHANES 2007–2018 participants aged ≥20 years with CKM stages 0–3, complete prespecified covariates, and a positive fasting-subsample weight. Leisure-time physical activity (LTPA) was categorized as inactive (0 min/week), insufficient (>0 to <150 min/week), or sufficient (≥150 min/week); daily sitting time was categorized as <6, 6 to <8, or ≥8 h/day. The primary outcome was all-cause mortality; cardiovascular disease (CVD) and non-CVD mortality were secondary outcomes. Survey-design-based Cox models incorporated the 12-year fasting weight, strata, and primary sampling units. Multiplicative and additive interactions were assessed. Results: During a median follow-up of 6.75 years, 670 deaths occurred, including 175 CVD and 495 non-CVD deaths. In fully adjusted models, sufficient versus no LTPA was associated with lower all-cause (hazard ratio [HR], 0.630; 95% confidence interval [CI], 0.483–0.822), CVD (HR, 0.536; 95% CI, 0.297–0.969), and non-CVD mortality (HR, 0.662; 95% CI, 0.478–0.916). Sitting ≥8 versus <6 h/day was associated with higher all-cause (HR, 1.506; 95% CI, 1.253–1.810), CVD (HR, 1.845; 95% CI, 1.246–2.732), and non-CVD mortality (HR, 1.406; 95% CI, 1.109–1.782). Compared with sufficient LTPA and sitting <6 h/day, <150 min/week of LTPA combined with sitting ≥8 h/day was associated with all-cause (HR, 1.972; 95% CI, 1.429–2.721), CVD (HR, 2.493; 95% CI, 1.232–5.045), and non-CVD mortality (HR, 1.806; 95% CI, 1.202–2.712). Multiplicative interaction was not detected for all-cause (P = 0.951) or non-CVD mortality (P = 0.274); the CVD interaction signal (P = 0.016) was exploratory because it depended on a joint category with few events. Conclusion: Higher LTPA and shorter sitting time were independently associated with lower mortality among US adults with CKM stages 0–3. Joint categories identified a higher-risk behavioral pattern, but did not establish that LTPA offsets the risk of prolonged sitting. Supplementary information: The online version contains supplementary material available at https://doi.org/10.1265/ehpm.26-00088.
SN - 1347-4715
SN - 1342-078X
ER -