Association between physical activity and pulmonary function among middle-aged and older adults

doi:10.21203/rs.3.rs-4690800/v1

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Association between physical activity and pulmonary function among middle-aged and older adults

https://doi.org/10.21203/rs.3.rs-4690800/v1

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Objective: Regular physical activity has several health benefits, and it is critical to investigate whether it also has advantages in pulmonary function for the general population. Therefore, this study aimed to explore the association between regular physical activity and the decline in pulmonary function among middle-aged and older South Korean population.

Methods: Data from 2014 to 2019 of Korean National Health and Nutrition Examination Survey were analyzed. Physical activity was measured using Global Physical Activity Questionnaire, and it was defined as sufficiently active groups and performing more than 2 days per week of muscle-strengthening exercisesaccording to guidelines. Pulmonary function was measured based on spirometry results. Using multiple logistic regression analyses, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.

Results: Of the 16,014 population over the age of 40, 7,177 were male and 8,837 were female participants, with 36.3% male and15.8% of female having pulmonary functional defects. After adjusting all covariates, the male population who performed physical activity had significantly lower likelihoods of pulmonary function defect (OR: 0.86, CI: 0.75–0.97) than inactivity group. This association was prominent in recreation-related and muscle-strengthening activity. However, the results of female population were not significant (OR: 1.04, CI: 0.88–1.23).

Conclusions:Engaging in physical activity were associated with lower likelihoods of pulmonary dysfunction in male population. Regular physical activities might be recommended for improved pulmonary function in this group, with more emphasis on recreation-related, muscle strengthening activities.

physical activity

pulmonary function

restrictive pattern

recreation

muscle-strengthening

According to the World Health Organization (WHO), physical activity is defined as any movement driven by skeletal muscles that requires energy expenditure [1]. The practice of physical activity offers numerous advantages for health, including the prevention of diseases, enhancement of quality of life, and promotion of healthy aging [2-4], while on the contrary, physical inactivity leads to substantial economic burdens and health issues at both individual and population levels [5].

In the realm of health promotion, daily engagement in physical activities is correlated with, albeit not necessarily synonymous to, an improved status of functional capacity [6]. The pinnacle of one's functional capacity, their maximum performance potential, can be affected by factors such as physical fitness or damage caused by diseases [7]. Among various physical functions, decline in pulmonary function can notably impede an individual's capacity to perform optimally. Although the decline in pulmonary function is associated with aging, this decrease can pose a significant risk for several diseases including chronic obstructive pulmonary disease and ultimately lead to premature mortality within the population [8]. Considering ongoing worldwide trend towards an aging demographic and the resulting implications, preventing decline in pulmonary function is critical in promoting a healthy life expectancy [9]. Therefore, it becomes imperative to explore the potential benefits of regular physical activity in promoting healthy aging and whether such activities could potentially mitigate the decline in pulmonary function.

While previous research has explored the association between physical activity and pulmonary function, many of these studies focused on specific population subsets with risk factors for declining pulmonary function including population with particular diseases such as chronic obstructive pulmonary disease or male smokers [10-12]. These studies often had limited sample sizes [13], and factors affecting pulmonary function could vary across different contexts due to genetic disparities, environmental influences, and dietary habits [14]. Moreover, health consequences also may vary depending on the sort of physical activity [15-17]. Hence, there is a need to investigate the broader population using objective tools to measure pulmonary function, and consider the type of physical activity.

Given the numerous negative impacts of pulmonary function [18], an investigation into the advantages of pulmonary function through regular physical activity may be required from a public health standpoint. Therefore, this cross-sectional study was primarily aimed to explore the association between regular physical activity and the decline in pulmonary function among middle-aged and older population in South Korea.

2.1. Data

Data from the 6-year (2014–2019) Korean National Health and Nutrition Examination Survey (KNHANES), conducted by the Korean Disease Control and Prevention Agency (KDCA), were analyzed in this study. The KNHANES employed a stratified, multistage cluster-sampling design on a representative nationwide South Korean population [19]. The World Health Organization's (WHO) Global Physical Activity Questionnaire (GPAQ) guideline was reflected in the KNHANES starting in 2014, and the COVID-19 pandemic triggered to suspend the pulmonary function test starting in year 2020. Hence, this study employed KNHANES data from 2014 to 2019. As the use of raw data of KNHANES is publicly available, ethics approval was exempt. All responses from participants in KNHANES are collected anonymously from the KDCA.

2.2. Study population

In the 2014–2019 KNHANES, all participants were recorded for the study population (n=47,309). Firstly, to acquire the results of the pulmonary function test, we excluded those who were not subjected to the test, those below the age of 40, and those who did not have the test results (n=28,795). Of the remaining 18,514 participants, excluding the case of lung-related diseases on-going prevalence (tuberculosis [n=9], lung cancer [n=12], asthma [n=333], chronic obstructive pulmonary disease [n=50]; total n=377 with 27 overlapped) and the case with missing variables used in this study (n=2,123), the final study population comprised 16,014 participants. Due to the restricted number of pulmonary function test participants, individuals with pulmonary function test results in the overall dataset are assigned a distinct weighted value in the relevant analysis.

2.3. Variables

2.3.1. Physical activity

Physical activity, the variable of interest, was measured using GPAQ [20]. The WHO established the GPAQ, a standardized questionnaire that assesses physical activity by three distinct domains (work, recreation, and transport) and is currently used in 100 countries. Responded Moderate- and vigorous-intensity of physical activity in each domain was calculated as Metabolic Equivalents for Task (MET)-minute per week as follows:

intensity of physical activity × minute per day × times per week

The intensity of physical activity score was 8.0 at vigorous physical activity and 4.0 at moderate or transport-related physical activity. Given that the respondents were above 40 years old, we determined a sufficiently active categorization as performing physical activity consistent with the GPAQ guidelines: at least 30 minutes of moderate-intensity activity or walking per day on at least five days of a typical week; 20 minutes of vigorous-intensity activity per day on at least three days of a typical week; or 5 days of any combination of walking and moderate- or vigorous-intensity activities totaling at least 600 MET-minutes per week [21]. In addition, since the guidelines recommend that this age group perform muscle-strengthening activities 2 or more days a week, this study finally defined it as participating in regular physical activities, including this activity [1]. For subgroups, questionnaire domain of physical activity was divided into four groups based on a large proportion of the individual's MET score: (1) work, (2) recreation, (3) transport, and (4) inactive. Type of physical activity was divided into four groups based on aerobic or muscle-strengthening physical activity: (1) aerobic, (2) muscle-strengthening, (3) both types, and (4) inactive. Furthermore, intensity of physical activity was divided into three groups based on individual's MET score: (1) high (≥3,000 MET), (2) moderate (<3,000 MET), and (3) inactive (low).

2.3.2. Pulmonary function

Pulmonary function, the dependent variable, was measured using spirometry. Four technicians conducted spirometry using a dry rolling seal spirometer (Model 2130; SensorMedics, Yorba Linda, CA, USA) [22]. Survey data on non-smokers without a history of respiratory diseases or symptoms, as well as normal chest X-ray results, were used to create spirometric prediction equations. The results were interpreted using the proportion of forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV₁) compared to normal value of prediction equations. Four kinds of results were obtained: normal (FEV₁/FVC ≥70% and FVC ≥80%), restrictive pattern (FEV₁/FVC ≥70% and FVC <80%), obstructive pattern (FEV₁/FVC <70% and FVC ≥80%), and mixed pattern (FEV₁/FVC <70% and FVC <80%) [23]. Pulmonary functional defect was defined as restrictive, obstructive, and mixed pattern in this study. For subgroups, each four categories of variables were examined.

2.3.3. Related covariates

The following variables were entered in the model as potential covariates based on previous studies [12, 13, 24]. Sociodemographic factors: sex, age, scale of residence, household income, education level, marital status, and three-groups of the longest occupation according to the Korean Standard Classification of Occupation [25], which is originally categorized into 10 (white collar: manager, professionals and related worker and office worker; pink collar: service worker and sales worker; and blue collar: agriculture/forestry/fishery, craft and related trades workers, machine operators and assemblers, labor workers, and soldier). Health behavioral or other related factors: body mass index, smoking status, pack-year of smoking, drinking (more than once in a month: yes or no), hypertension, diabetes, and the year variables.

2.4. Statistical analysis

Sex-specific factors can influence physical activity and pulmonary outcomes [26]. Accordingly, all analyses were sex-stratified, and the results were proposed in the same way. To identify the general characteristics of the study population, number and percentage were presented with the results of a chi-square test. Multiple logistic regression analysis was performed to identify the association between physical activity and pulmonary function. For subgroup analyses, stratification of other covariates, pattern of pulmonary function defect, and physical activity were examined to investigate detail relationship. In subgroup analysis for pattern of pulmonary function, multinomial logistic regression was utilized owing to the multinomial category of dependent variable. The association between all variables in this study was estimated using odds ratios (ORs) and 95% confidence intervals (CIs). SAS version 9.4M6 (SAS Institute, Cary, NC, USA) was used for all statistical analyses.

Table 1 describes the sex-stratified general characteristics of the study population. In the total 16,014 participants, 7,177 were male and 8,837 were female participants. 2,629 (36.3%) of male and 1,394 (15.8%) of female participants had pulmonary functional defects. Additionally, 2,735 (38.1%) of male and 2,002 (22.7%) of female participants engaged in physical activity. The results of chi-square test for physical activity and pulmonary function were significant among males (p<0.0001) and females (p<0.0114).

Table 2 shows the results of the multiple logistic regression analysis of physical activity and pulmonary function. After adjusting all covariates, the male population who performed physical activity had significantly lower likelihoods of pulmonary function defect (OR: 0.86, CI: 0.75–0.97) than inactivity group. The same analytic results of the female population (OR: 1.04, CI: 0.88–1.23) were not significant.

Table 3 shows the covariate-stratified results of the subgroup analysis. Compared with the inactivity group, male participants who performed physical activity with high household income (high, OR: 0.85, CI: 0.67–1.08; middle-high, OR: 0.73, CI: 0.57–0.93), high education level (OR: 0.80, CI: 0.65–0.99), high body mass index (obesity, OR: 0.78, CI: 0.66–0.92), and high pack-year of smoking (over 20 years, OR: 0.82, CI: 0.68–0.99) had lower likelihoods of pulmonary dysfunction.

Table 4 shows the results of the subgroup analysis stratified by physical activity. In results of questionnaire domain stratification, male participants who performed recreation-related physical activity had significantly lower likelihoods of pulmonary dysfunction (OR: 0.78, CI: 0.67–0.91) than inactive population. Transport-related physical activity had a lower likelihood (OR: 0.88, CI: 0.73–1.06), but not significant. Conversely, work-related physical activity had a higher likelihood (OR: 1.16, CI: 0.86–1.58), but not significant. In results of type stratification, male participants who performed only muscle-strengthening physical activity had significantly lower likelihoods of pulmonary dysfunction (OR: 0.81, CI: 0.69–0.95) than inactive population. Other category of physical activity had lower likelihoods of pulmonary dysfunction [aerobic, (OR: 0.88, CI: 0.71–1.10); both types, (OR: 0.92, CI: 0.74–1.13)], but not significant. In results of intensity stratification, male participants who performed moderate intensity of physical activity had significantly lower likelihoods of pulmonary dysfunction (OR: 0.85, CI: 0.74–0.96) than inactive population. High intensity of male participants who were over 3,000 MET also had lower likelihoods of pulmonary dysfunction (OR: 0.90, CI: 0.66–1.23), but not significant.

Figure 1 displays the results of the multinomial logistic regression analysis for the subgroup stratified by the pattern of pulmonary function defect. Pulmonary function results were present as normal, restrictive, obstructive, or mixed patterns. Compared with the inactive male participants, the physical activity group had significantly lower likelihoods of pulmonary defect especially in restrictive patterns (OR: 0.74, CI: 0.62–0.88). The results of obstructive pattern (OR: 0.90, CI: 0.69–1.17) showed slightly higher likelihoods and mixed pattern (OR: 0.79, CI: 0.51–1.23) were lower, but two patterns were not significant. The results of female participants indicated no significance, which was consistent with the results in Table 2.

This study investigated the association between engaging in physical activity and pulmonary functional defect among the nationally representative South Korean middle-aged and older population. This study found that physical activity was associated with lower likelihoods of declines in pulmonary function among the male population. This association was mainly linked with restrictive patterns of the pulmonary dysfunction. Additionally, the most prominent association was observed when participating in recreation-related and muscle-strengthening physical activities. However, the association among female population were not significant after adjusting all covariates.

Previous studies that examined the association between physical activity and pulmonary function in smokers mainly suggested the underlying mechanism as systemic anti-inflammatory effects enhanced by physical activity [10, 24]. One study’s findings emphasized this mechanism because the pulmonary functional benefit from physical activity was observed only in the current smoker group [24]. However, studies examining the entire population have indicated that both individuals who smoke and those who do not smoke exhibit similar associations, which aligns with the findings of present study [14, 27]. Accordingly, as general potential explanation, the decline in lung elastic recoil linked to aging can lead to early airway constriction and a decrease in lung function [27]. It can also be suggested that engaging in physical activity serves as a mechanism to counterbalance the tendency towards chest wall rigidity caused by this loss of elasticity [27].

The present study revealed a significant result concerning the restrictive pattern of decline in pulmonary function. The incorporation of regular physical activity definition, encompassing both aerobic and muscle-strengthening exercises, may have contributed to the potential improvement in FVC by directly enhancing the respiratory muscles [14]. As the final effector of motor unit output, skeletal muscle, which can be primarily reinforced by muscle-strengthening exercises, regulates a variety of motor processes, such as breathing [28]. Alternatively, another study has been proposed explanation: regular physical activity helps avoid weight gain, which is associated with accelerated FVC decline and ultimately induces a restrictive pattern defect, and the other involves improving the systemic anti-inflammatory effects of physical activity [29].

After adjusting for all covariates, the significant findings were exclusively prominent in males, with no corresponding impact observed in females. This discrepancy based on gender could be attributed to variations in how the lungs of males and females respond to exercise [30]. Factors such as structural variances in lung physiology, airway function, or ventilation based on hormonal influences, as well as psychological disparities in coping with exertional breathlessness, are postulated as plausible clarifications [31].

Distinct from other domain of physical activity, recreation-related physical activity has demonstrated a substantial impact, possibly attributable to the positive psychological effects derived from enjoying such recreational pursuits [32]. Furthermore, this phenomenon could be interpreted as a consequence of the fact that engaging in recreation-related physical activities fosters a heightened sense of motivation for active participation during exercise time [32]. Notably, males' inclination towards such activities, unlike females, may stem from a strong emphasis on achieving mastery, seeking competition, and enhancing ego through participation [33].

The analysis of subgroups stratified by various covariates revealed a correlation observed at high socioeconomic status levels such as household income and education, which could be attributed to the association of high socioeconomic status with increased engagement in physical activities related to leisure [34]. Moreover, obesity is specifically associated to decreased pulmonary function with a restrictive pattern [35], implying that physical activity might mitigate the impact of obesity. Among individuals with a history of smoking exceeding 20 pack years, physical activity is perceived as a means of delaying or reversing the deterioration in pulmonary function caused by smoking, mirroring findings from preceding research studies discussed earlier.

The advantages of the current study include the use of a representative sample from South Korea, a GPAQ to quantify physical activity with diverse types, which allows for comparisons with the results of other countries, and objective assessment of pulmonary function test results. Future research might investigate the longitudinal relationship between these two variables, as well as alternative approaches for assessing and researching physical activity.

Nevertheless, this study has several limitations. Firstly, establishing a causal relationship is challenging due to the cross-sectional nature of the study; indeed, some studies suggest the potential for a bidirectional relationship [12]. Secondly, the presence of recall bias is possible for variables measured in a self-reported format. Thirdly, concerns regarding the validity of the GPAQ exist, with a likelihood of bias towards null association, particularly among female participants [36]. Additionally, issues related to the accuracy of smoking-related variables in female [37], crucial for understanding pulmonary function, may arise when relying on self-report methods, potentially impacting the study outcomes. Fourthly, generalizing findings to individuals under 40 years of age or those with conditions affecting pulmonary function decline may pose challenges. Lastly, there might be unmeasured confounding variables influencing the association between physical activity and pulmonary function.

Findings indicated that male population who performed physical activity, particularly recreation-related and muscle strengthening, had lower likelihoods of pulmonary dysfunction than inactive population. Additionally, this association was pronounced in restrictive patterns of the pulmonary dysfunction. Therefore, physical activities that focus muscular strength and are practiced recreationally might be recommended for preventing or postponing the defect of pulmonary function.

GPAQ: Global physical activity questionnaire

MET: Metabolic Equivalents of Task

FVC: Forced vital capacity

FEV₁: Forced expiratory volume at 1 second

OR: Odds ratio

CI: Confidence interval

WHO: World Health Organization

KNHANES: Korean National Health and Nutrition Examination Survey

KDCA: Korean Disease Control and Prevention Agency

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Author contributions

JHL: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing -original draft, Writing - review & editing. YSJ: Writing - review & editing. DBK: Conceptualization, Writing - review & editing. MJJ: Writing - review & editing. ECP: Conceptualization, Methodology, Project administration, Supervision. SIJ: Conceptualization, Methodology, Project administration, Supervision, Writing -original draft, Writing - review & editing.

Data availability statement

The datasets of this study are openly available in the Korea National Health and Nutrition Examination Survey (KNHANES) website at https://knhanes.kdca.go.kr/knhanes/main.do

Ethics approval statement

Ethics approval was exempt since the raw data of KNHANES are publicly available and all participants in KNHANES are investigated anonymously by the Korea Disease Control and Prevention Agency (KDCA).

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Tables 1 to 4 are available in the Supplementary Files section.

No competing interests reported.

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Association between physical activity and pulmonary function among middle-aged and older adults

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1. Introduction

2. Methods

3. Results

4. Discussion

5. Conclusion

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