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Journal of Peking University (Health Sciences) ›› 2025, Vol. 57 ›› Issue (3): 537-544. doi: 10.19723/j.issn.1671-167X.2025.03.018

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Prospective association between physical activity and mortality in patients with chronic obstructive pulmonary disease

Shuo ZHANG1, Yongbing LAN1, Dianjianyi SUN1,2,3, Pei PEI2, Huaidong DU4, Junshi CHEN5, Zhengming CHEN4, Jun LV1,2,3,6, Liming LI1,2,3, Canqing YU1,2,3,*(), (for the China Kadoorie Biobank Collaborative Group)   

  1. 1. Department of Epidemiology & Biostatistics, Peking University School of Public Health, Beijing 100191, China
    2. Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing 100191, China
    3. Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing 100191, China
    4. Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
    5. China National Center for Food Safety Risk Assessment, Beijing 100022, China
    6. State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, Beijing 100191, China
  • Received:2025-02-04 Online:2025-06-18 Published:2025-06-13
  • Contact: Canqing YU
  • Supported by:
    the Noncommunicable Chronic Diseases-National Science and Technology Major Project(2023ZD0510100); National Natural Science Foundation of China(82192901); National Natural Science Foundation of China(82192904); National Natural Science Foundation of China(82192900); National Natural Science Foundation of China(82388102); Wellcome grants to Oxford University(212946/Z/18/Z); Wellcome grants to Oxford University(202922/Z/16/Z); Wellcome grants to Oxford University(104085/Z/14/Z); Wellcome grants to Oxford University(088158/Z/09/Z); Kadoorie Charitable Foundation in Hong Kong

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Abstract:

Objective: To explore the prospective association between physical activity level and mortality risk in Chinese adults with chronic obstructive pulmonary disease (COPD). Methods: Based on the China Kadoorie Biobank (CKB) who had COPD at the baseline survey, this study employed the Cox proportional hazards regression model to estimate the prospective associations between the overall physical activity, different intensities (low-level, moderate-to-vigorous-level), and types (occupational, non-occupational) of physical activity level and the risks of all-cause and cause-specific mortality, such as vascular diseases, cancer, and respiratory diseases. Based on the quintiles of physical activity level, participants were divided into five groups (Q1-Q5), with the lowest quintile group (Q1) as the reference group. Hazard ratio (HR) and 95% confidence interval (95%CI) were calculated for the remaining. In our study, we also performed sensitivity and subgroup analyses, including age, gender, self-rated health status, severity of COPD, etc. Results: Among 33 588 COPD patients at the baseline survey, 8 314 (22.2%) deaths were documented during an average follow-up of (11.1±3.1) years. Negative linear associations between the overall physical activity level and mortality risk from all-cause, vascular, and respiratory diseases were observed (P trend for linear correlation being < 0.001, 0.002, < 0.001). Compared with the lowest quintile group of total physical activity (Q1), the hazard ratios (HR) and 95% confidence intervals (CI) for all-cause mortality, vascular disease mortality, and respiratory disease mortality in the highest quintile group (Q5) were 0.77 (0.70, 0.85), 0.77 (0.65, 0.91), and 0.58 (0.48, 0.71), respectively. The low-level and moderate-to-vigorous-level physical activity were negatively associated with all-cause mortality in the COPD patients (P trend for linear correlation: 0.002, < 0.001, respectively). Compared with the lowest quintile group of low-intensity and moderate-to-vigorous intensity physical activity (Q1), the HRs (95%CI) for all-cause mortality in the highest quintile group (Q5) were 0.89 (0.82, 0.97) and 0.79 (0.72, 0.87), respectively. The occupational and non-occupational physical activity were also found to have a linear inverse association with all-cause mortality risk among the COPD patients (P trend < 0.001 and 0.015, respectively). Compared with the lowest quintile group of occupational and non-occupational physical activity (Q1), the HR (95%CI) for all-cause mortality in the highest quintile group (Q5) were 0.69 (0.61, 0.78) and 0.91 (0.84, 0.98), respectively. The associations between overall physical activity and all-cause mortality risk were stronger for patients aged 60 and above, female, and who reported poor health status (P for interaction: 0.028, 0.012, 0.010). The protective effect of total physical activity was also applicable to the COPD patients of varying severity. Conclusion: Physical activity could reduce the mortality risk in a dose-response relationship among COPD patients, regardless of its intensity and type, especially among individuals aged 60 and above, females, and those with poor self-report health status.

Key words: Chronic obstructive pulmonary disease, Physical activity, Mortality, Prospective association

CLC Number: 

  • R184

Table 1

Baseline characteristics of COPD participants by level of total physical activity"

Characteristic Quintiles of total physical activity F/χ2 P
Q1 (n=6 774) Q2 (n=6 668) Q3 (n=6 731) Q4 (n=6 698) Q5 (n=6 717)
Age/years，${\bar x}$±s 64.4±8.8 61.6±9.7 58.1±10.5 55.0±10.3 52.0±9.5 1 746.7 < 0.001
Gender, n (%) 1 155.9 < 0.001
  Female 2 405 (35.5) 4 174 (62.6) 3 655 (54.3) 3 697 (55.2) 3 009 (44.8)
  Male 4 369 (64.5) 2 494 (37.4) 3 076 (45.7) 3 001 (44.8) 3 708 (55.2)
Area, n (%) 538.2 < 0.001
  Urban 3 069 (45.3) 2 714 (40.7) 2 275 (33.8) 1 842 (27.5) 2 317 (34.5)
  Rural 3 705 (54.7) 3 954 (59.3) 4 456 (66.2) 4 856 (72.5) 4 400 (65.5)
Married, n (%) 19.44 0.001
  Married 5 731 (84.6) 5 661 (84.9) 5 829 (86.6) 5 800 (86.6) 5 803 (86.4)
  Other 1 043 (15.4) 1 007 (15.1) 902 (13.4) 898 (13.4) 914 (13.6)
Education, n (%) 86.72 < 0.001
  Middle school and higher 2 249 (33.2) 2 174 (32.6) 2 214 (32.9) 2 043 (30.5) 1 840 (27.4)
  Primary school and lower 4 525 (66.8) 4 494 (67.4) 4 517 (67.1) 4 655 (69.5) 4 877 (72.6)
Household income, n (%) 55.75 < 0.001
  ≥20 000 yuan/year 2 113 (31.2) 2 274 (34.1) 2 430 (36.1) 2 197 (32.8) 2 230 (33.2)
   < 20 000 yuan/year 4 661 (68.8) 4 394 (65.9) 4 301 (63.9) 4 501 (67.2) 4 487 (66.8)
Occupation, n (%) 3 949.37 < 0.001
  Agriculture and industrial 2 174 (32.1) 2 634 (39.5) 4 146 (61.6) 4 930 (73.6) 5 145 (76.6)
  Other occupation 4 600 (67.9) 4 034 (60.5) 2 585 (38.4) 1 768 (26.4) 1 572 (23.4)
Regular consumption of meat, n (%) 31.86 < 0.001
  ≥4 d/week 2 757 (40.7) 2 674 (40.1) 2 612 (38.8) 2 451 (36.6) 2 646 (39.4)
   < 4 d/week 4 017 (59.3) 3 994 (59.9) 4 119 (61.2) 4 247 (63.4) 4 071 (60.6)
Regular consumption of fresh vegetables, n (%) 12.81 0.012
  ≥4 d/week 6 672 (98.5) 6 588 (98.8) 6 643 (98.7) 6 571 (98.1) 6 616 (98.5)
   < 4 d/week 102 (1.5) 80 (1.2) 88 (1.3) 127 (1.9) 101 (1.5)
Regular consumption of fresh fruit, n (%) 104.56 < 0.001
  ≥4 d/week 1 531 (22.6) 1 607 (24.1) 1 602 (23.8) 1 326 (19.8) 1 209 (18.0)
   < 4 d/week 5 243 (77.4) 5 061 (75.9) 5 129 (76.2) 5 372 (80.2) 5 508 (82.0)
Drinking status, n (%) 52.19 < 0.001
  Current weekly drinker 2 683 (39.6) 2 627 (39.4) 2 706 (40.2) 2 693 (40.2) 2 821 (42.0)
  Non-current weekly drinker 4 091 (60.4) 4 041 (60.6) 4 025 (59.8) 4 005 (59.8) 3 896 (58.0)
Smoking status, n (%) 18.58 0.001
  Current daily smoker 1 009 (14.9) 1 014 (15.2) 1 198 (17.8) 1 192 (17.8) 1 243 (18.5)
  Non-current smoker 5 765 (85.1) 5 654 (84.8) 5 533 (82.2) 5 506 (82.2) 5 474 (81.5)
BMI/(kg/m2)，${\bar x}$±s 22.8±3.8 22.8±3.7 22.8±3.5 22.5±3.4 22.5±3.2 10.65 < 0.001
Sedentary/ (h/d)，${\bar x}$±s 3.5±2.0 3.5±1.8 3.1±1.6 2.7±1.5 2.5±1.4 390.75 < 0.001
GOLD, n (%) 456.27 < 0.001
  1 1 687 (24.9) 1 840 (27.6) 2 006 (29.8) 1 942 (29.0) 2 042 (30.4)
  2 3 184 (47.0) 3 194 (47.9) 3 150 (46.8) 3 275 (48.9) 3 379 (50.3)
  3 1 429 (21.1) 1 300 (19.5) 1 292 (19.2) 1 233 (18.4) 1 101 (16.4)
  4 474 (7.0) 334 (5.0) 283 (4.2) 248 (3.7) 195 (2.9)
Self-assessed health status, n (%) 362.41 < 0.001
  Excellent 644 (9.5) 785 (11.8) 828 (12.3) 824 (12.3) 804 (11.9)
  Good 1 361 (20.1) 1 426 (21.4) 1 615 (24.0) 1 567 (23.4) 1 798 (26.8)
  Average 2 994 (44.2) 3 065 (45.9) 3 110 (46.2) 3 182 (47.5) 3 054 (45.5)
  Poor 1 775 (26.2) 1 392 (20.9) 1 178 (17.5) 1 125 (16.8) 1 061 (15.8)
Coronary heart disease, n (%) 46.98 < 0.001
  Yes 318 (4.7) 280 (4.2) 269 (4.0) 174 (2.6) 154 (2.3)
  No 6 456 (95.3) 6 388 (95.8) 6 462 (96.0) 6 524 (97.4) 6 563 (97.7)
Diabetes, n (%) 62.14 < 0.001
  Yes 271 (4.0) 240 (3.6) 168 (2.5) 147 (2.2) 114 (1.7)
  No 6 503 (96.0) 6 428 (96.4) 6 563 (97.5) 6 551 (97.8) 6 603 (98.3)
Kidney disease, n (%) 14.35 0.006
  Yes 163 (2.4) 120 (1.8) 108 (1.6) 127 (1.9) 101 (1.5)
  No 6 611 (97.6) 6 548 (98.2) 6 623 (98.4) 6 571 (98.1) 6 616 (98.5)
Stroke, n (%) 101.74 < 0.001
  Yes 217 (3.2) 133 (2.0) 94 (1.4) 60 (0.9) 60 (0.9)
  No 6 557 (96.8) 6 535 (98.0) 6 637 (98.6) 6 638 (99.1) 6 657 (99.1)

Table 2

Associations of total physical activity with mortality risk in COPD patients"

Quintiles of total physical activity P
Q1 Q2 Q3 Q4 Q5
All-cause mortality
  Number of deaths, n 2 764 1 955 1 558 1 195 842
  Mortality rate/% 40.4 26.8 20.5 15.5 10.6
  Model 1, HR(95%CI) 1.00 0.83 (0.78, 0.88) 0.76 (0.70, 0.81) 0.69 (0.63, 0.74) 0.63 (0.58, 0.69) < 0.001
  Model 2, HR(95%CI) 1.00 0.90 (0.84, 0.95) 0.85 (0.79, 0.91) 0.78 (0.72, 0.85) 0.77 (0.70, 0.85) < 0.001
Vascular disease mortality
  Number of deaths, n 1 069 749 506 372 244
  Mortality rate/% 15.6 10.3 6.7 4.8 3.1
  Model 1, HR(95%CI) 1.00 0.81 (0.74, 0.89) 0.75 (0.66, 0.84) 0.73 (0.63, 0.84) 0.66 (0.56, 0.77) < 0.001
  Model 2, HR(95%CI) 1.00 0.88 (0.80, 0.97) 0.83 (0.73, 0.93) 0.82 (0.71, 0.94) 0.77 (0.65, 0.91) 0.002
Malignant tumor mortality
  Number of deaths, n 619 470 383 327 287
  Mortality rate/% 9.1 6.4 5.1 4.2 3.6
  Model 1, HR(95%CI) 1.00 1.01 (0.90, 1.15) 0.91 (0.79, 1.05) 0.88 (0.75, 1.03) 0.88 (0.74, 1.04) 0.105
  Model 2, HR(95%CI) 1.00 1.03 (0.91, 1.16) 0.94 (0.82, 1.09) 0.91 (0.77, 1.08) 0.92 (0.78, 1.10) 0.293
Respiratory disease mortality
  Number of deaths, n 702 493 427 288 165
  Mortality rate/% 10.3 6.8 5.6 3.7 2.1
  Model 1, HR(95%CI) 1.00 0.74 (0.66, 0.83) 0.61 (0.53, 0.70) 0.45 (0.38, 0.53) 0.37 (0.31, 0.46) < 0.001
  Model 2, HR(95%CI) 1.00 0.86 (0.76, 0.97) 0.76 (0.66, 0.87) 0.58 (0.49, 0.69) 0.58 (0.48, 0.71) < 0.001

Table 3

Subgroup analysis for the associations of total physical activity with all-cause mortality risk in COPD patients"

Quintiles of total physical activity P(LR χ2)
Q1 Q2 Q3 Q4 Q5
Age group/years 0.028 (7.12)
  30- 1.00 1.19 (0.76, 1.86) 1.06 (0.68, 1.65) 1.02 (0.66, 1.59) 1.15 (0.75, 1.77)
  50- 1.00 0.88 (0.73, 1.06) 0.86 (0.71, 1.04) 0.81 (0.67, 0.99) 0.81 (0.66, 0.99)
  60- 1.00 0.90 (0.84, 0.96) 0.85 (0.79, 0.92) 0.79 (0.72, 0.87) 0.77 (0.68, 0.86)
Area 0.125 (2.35)
  Rural 1.00 0.89 (0.83, 0.96) 0.85 (0.78, 0.92) 0.79 (0.72, 0.86) 0.75 (0.68, 0.83)
  Urban 1.00 0.93 (0.84, 1.04) 0.88 (0.77, 1.01) 0.80 (0.65, 0.97) 0.86 (0.70, 1.06)
Gender 0.012 (6.24)
  Male 1.00 0.90 (0.83, 0.97) 0.90 (0.82, 0.98) 0.83 (0.75, 0.92) 0.81 (0.73, 0.91)
  Female 1.00 0.86 (0.78, 0.95) 0.77 (0.68, 0.87) 0.67 (0.58, 0.77) 0.64 (0.53, 0.76)
Smoking status 0.109 (2.57)
  Non-current smoker 1.00 0.91 (0.83, 0.99) 0.82 (0.74, 0.92) 0.76 (0.67, 0.86) 0.71 (0.61, 0.82)
  Current daily smoker 1.00 0.88 (0.81, 0.96) 0.86 (0.78, 0.95) 0.79 (0.71, 0.88) 0.79 (0.70, 0.89)
Drinking status 0.004 (8.12)
  Non-current weekly drinker 1.00 0.92 (0.86, 0.98) 0.86 (0.80, 0.93) 0.78 (0.71, 0.85) 0.77 (0.69, 0.86)
  Current weekly drinker 1.00 0.74 (0.62, 0.87) 0.75 (0.63, 0.89) 0.74 (0.61, 0.89) 0.71 (0.58, 0.87)
Sedentary/(h/d) 0.158 (1.99)
   < 3 1.00 0.91 (0.82, 1.00) 0.83 (0.75, 0.93) 0.78 (0.68, 0.88) 0.75 (0.66, 0.86)
  ≥3 1.00 0.88 (0.81, 0.95) 0.85 (0.77, 0.93) 0.78 (0.70, 0.87) 0.78 (0.68, 0.89)
GOLD 0.016 (8.32)
  1 1.00 0.92 (0.78, 1.09) 0.84 (0.69, 1.03) 0.76 (0.60, 0.95) 0.76 (0.60, 0.97)
  2 1.00 0.95 (0.87, 1.04) 0.95 (0.85, 1.06) 0.91 (0.81, 1.04) 0.87 (0.76, 1.00)
  3-4 1.00 0.82 (0.75, 0.90) 0.74 (0.66, 0.82) 0.66 (0.58, 0.74) 0.64 (0.55, 0.75)
BMI/(kg/m2) 0.003 (14.30)
  Underweight 1.00 0.86 (0.75, 0.99) 0.78 (0.66, 0.92) 0.64 (0.53, 0.78) 0.57 (0.45, 0.71)
  Normal weight 1.00 0.88 (0.81, 0.95) 0.80 (0.73, 0.89) 0.73 (0.65, 0.81) 0.71 (0.63, 0.80)
  Overweight 1.00 0.86 (0.75, 0.98) 0.81 (0.69, 0.96) 0.91 (0.75, 1.11) 0.77 (0.61, 0.96)
  Obese 1.00 1.02 (0.78, 1.33) 1.08 (0.81, 1.44) 0.60 (0.39, 0.91) 0.80 (0.49, 1.32)
Self-assessed health status 0.010 (11.34)
  Excellent 1.00 0.99 (0.78, 1.24) 0.91 (0.69, 1.20) 0.90 (0.65, 1.23) 0.95 (0.68, 1.33)
  Good 1.00 0.87 (0.75, 1.02) 0.82 (0.69, 0.98) 0.78 (0.64, 0.95) 0.70 (0.57, 0.86)
  Average 1.00 0.87 (0.80, 0.95) 0.87 (0.78, 0.96) 0.78 (0.69, 0.88) 0.73 (0.63, 0.84)
  Poor 1.00 0.85 (0.76, 0.95) 0.71 (0.62, 0.81) 0.61 (0.53, 0.71) 0.58 (0.48, 0.71)

Figure 1

Associations between different intensities of physical activity and all-cause mortality risk in COPD patients LPA was divided into 5 parts according to quintiles, and the boundaries are 0-, 2.8-, 6.0-, 8.6-, 12.9-42.67 MET-hours/day; MVPA was divided into 5 parts according to quintiles, and the boundaries are 0-, 0.1-, 2.9-, 6.6-, 21.1-101.9 MET-hours/day; results are presented as HR (95%CI) and based on model 2. PA, physical activity; LPA low-level physical activity; MVPA moderate-to-vigorous-level physical activity; MET, metabolic equivalent of the task; COPD, chronic obstructive pulmonary disease."

Figure 2

Associations between different types of physical activity and all-cause mortality risk in COPD patients Occupational PA was divided into 5 parts according to quintiles, and the boundaries are 0-, 0.3-, 2.3-, 10.7-, 21.7-100 MET-hours/day; Non-occupational PA was divided into 5 parts according to quintiles, and the boundaries are 0-, 3.7-, 6.2-, 8.4-, 11.2-58.97 MET-hours/day; results are presented as HR (95%CI) and based on model 2. PA physical activity; MET, metabolic equivalent of the task; COPD, chronic obstructive pulmonary disease."

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