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Does compressing physical activity into one or two days still achieve cardiovascular benefits?

1st September 2023

With lack of time often cited as a barrier to undertaking physical activity, cramming a week‘s worth of exercise into a day or two may seem more achievable, especially if it provides comparable cardiovascular benefits to a more evenly distributed pattern. Hospital Healthcare Europe‘s clinical writer and resident pharmacist Rod Tucker considers the evidence.

It is abundantly clear that being physically active is associated with health benefits. Current guidance on physical activity for adults in most major countries in Europe is broadly similar: undertake either at least 150 minutes of moderate intensity activity a week or 75 minutes of vigorous intensity activity, plus two days a week of strengthening activities to work all of the main muscle groups.

Moreover, it is advocated that exercise is undertaken every day or spread evenly over four to five days a week.

But is there any evidence that achieving this amount of exercise is associated with health benefits? In a 2020 study, an international research group tried to answer this question.

The team looked at the association between attainment of the recommended amount of physical activity among a representative sample of US citizens, and all-cause and cause specific mortality.

Their analysis included 479,856 adults who were followed for a median of 8.75 years. The findings were very clear: undertaking the recommended amounts of physical activity reduced the risk of all-cause mortality by 40%. But not only that, such levels of activity lowered the risk of cardiovascular disease by 50% and the risk of cancer by 40%.

With clear evidence of the health benefits from undertaking the recommended levels of physical activity, surveys have also identified some notable and recognised barriers to exercising. One of the most consistently reported barriers is sufficient time to exercise, and this is seen irrespective of age and gender.

Compressing the time for exercise

Although healthcare professionals may advocate that their patients engage in exercise as part of the health promotion message, it seems they don‘t always practise what they preach. In fact, research shows that lack of time is also a perceived barrier to exercise among doctors and nurses.

As well as insufficient time, a demanding workload gives rise to high levels of burnout and stress, and changing shift patterns can limit time and motivation, which all represent additional barriers to exercising among clinicians.

Evidence suggests that exercising for just one or two days a week could accrue the same health benefits seen among those who exercise more regularly throughout the week. For example, so-called ‘weekend warriors‘ – those who restrict physical activity to just one or two sessions per week – have a similar level of all-cause mortality compared to those who spread their physical activity over several days.

In fact, a 2023 meta-analysis of four studies with 426,428 participants found that the risk of both cardiovascular disease mortality and all-cause mortality in those compressing their activity into two days was 27% and 17% lower, respectively, when compared to those who were inactive.

However, a limitation of this analysis was that levels of physical activity were self-reported and therefore prone to misclassification bias.

Weekend warrior activity and health outcomes

With inherent self-reporting bias an issue, a recent study examined the value of accelerometer-derived data. Researchers recently set out to examine the association between a weekend warrior pattern of moderate-to-vigorous physical activity (MVPA) achieved over just one to two days, compared to the activity being spread more evenly, with the risk of incident cardiovascular events.

The researchers retrospectively analysed a UK Biobank cohort who provided a full week‘s worth of wrist-based accelerometer physical activity data. Individuals were classified into three groups: active weekend warriors, in which more than half of their total MVPA was undertaken over one to two days; regularly active, where exercising was spread throughout the week; and inactive, where less than 150 minutes of MVPA per week was undertaken.

They looked at associations between the different activity pattern and cardiovascular outcomes such as incident atrial fibrillation, myocardial infarction, heart failure and stroke. The findings were then adjusted for several potential covariates including age, sex, ethnicity race, alcohol and smoking and diet quality.

Data for 89,573 individuals with a mean of 62 years (56% female) were included in the analysis and who were followed for a median of 6.3 years. Interestingly, when stratified at the threshold of 150 minutes or more of MVPA per week, nearly half of the entire cohort (42.2%) were classed as weekend warriors.

The findings for atrial fibrillation, myocardial infarction, heart failure and stroke are summarised in the table below.

Just keep moving

The accelerometer-derived study shows that engagement in physical activity, regardless of the pattern, is able to reduce the risk of a broad range of adverse cardiovascular outcomes. Therefore, although many healthcare professionals‘ working weeks may not permit specific exercising days, it seems that compressing physical activity into just two days per week, wherever possible, still achieves comparable health benefits.

So, whether it’s advice for patients or the foundation for personal fitness goals, the key message is to just keep moving.

‘Weekend warriors’ have similar mortality to regularly active individuals

18th July 2022

‘Weekend warriors’ and the regularly active have a similar mortality hence exercise is still beneficial when done in only one or two sessions

‘Weekend warriors’ who restrict physical activity to just one or two sessions per week appear to have similar levels of all-cause and cause-specific mortality compared to those who are regularly active, i.e., spread their physical activity over several days. This was the conclusion of a large, prospective cohort study by an international group of researchers.

Physical activity guidelines for Americans (and which are broadly similar across the world) recommend that adults should do at least 150 to 300 minutes a week of moderate-intensity, or 75 to 150 minutes a week of vigorous-intensity aerobic physical activity. In addition, the guidelines advocate muscle strengthening activities of moderate or greater intensity on two days or more each week.

Furthermore, the evidence to date suggests that when adults engage in the recommended levels of physical activity, there is a greatly reduced risk of all-cause and cause specific mortality. Only a single study has examined the mortality benefits achieved by weekend warriors and suggested that it may be sufficient to reduce all-cause mortality risks, in comparison to those who are insufficiently active.

However, it is less clear whether concentrating the recommended amounts of physical exercise into one or two sessions (e.g., weekend warriors) provides the same mortality benefits as observed by those who are physically active throughout the week.

In the present analysis, researchers examined the all-cause and cause-specific mortality between weekend warriors and those who were regularly active using data from the US National Health Interview Survey from 1997 to 2013 and linked this information to a national death index.

They classified individuals as physically active (150 minutes of activity/week) or inactive (< 150 minutes/week). Among those deemed physically active, individuals were sub-divided into weekend warriors (1 – 2 sessions/week) or regularly active (> 3 sessions/week).

The main outcomes of interest were all-cause, cardiovascular and cancer-related mortality. In regression models, adjustments were made for several factors including age, gender, ethnicity and various lifestyle factors such as smoking status, alcohol intake and co-morbidities.

Weekend warriors and all-cause mortality

A total of 350978 individuals with a mean age of 41.1 years (50.8% women) were followed-up for a median of 10.4 years. More than half (52.5%) were deemed physically inactive, 3% weekend warriors and the remaining 44.5% regularly active. During the period of follow-up there were 21 898 deaths including 4130 from cardiovascular disease and 6034 from cancer.

When compared to those deemed physically inactive, the adjusted hazard ratio (HR) for all-cause mortality was 0.92 (95% CI, 0.83 – 1.02) for weekend warriors and 0.85 (95% CI 0.83 – 0.88) for regularly active participants. The HR for cardiovascular disease mortality were also similar for weekend warriors (HR = 0.87) and and those who were regularly active (HR = 0.77), as were the cancer-related HRs.

But when researchers compared mortality between weekend warriors and those who were regularly active, the all-cause, cardiovascular and cancer-related mortality hazard ratios, were also very similar, even after adjustment for the amount and intensity of physical activity undertaken.

The authors concluded that there were no significant differences for any cause mortality among those who were physically active, irrespective of whether the sessions were undertaken throughout the week or concentrated into one or two sessions.

dos Santos M et al. Association of the “Weekend Warrior” and Other Leisure-time Physical Activity Patterns With All-Cause and Cause-Specific Mortality: A Nationwide Cohort Study JAMA Intern Med 2022