Physical inactivity is becoming a world-wide epidemic – and the consequences can be both costly and deadly. This was outlined by Dr. Jonathan Myers who, citing a range of studies and recent research results, was able to show hard-hitting data related to the correlation between fitness (or lack thereof) and poor health. Myers argues fitness may well be a better marker than traditional risk factors for CVD and all-cause mortality. Amongst the eye-opening findings presented to the audience was that, for the first time, global deaths-per-year due to physical inactivity are higher than for smoking.

2. Cardiorespiratory Fitness,
Health Outcomes, and Health
Care Costs: The Case for
Fitness as a Vital Sign
Jonathan Myers, Ph.D.
VA Palo Alto Health Care System
Stanford University

3. Cardiorespiratory Fitness, Health Outcomes, and
Health Care Costs: The Case for Fitness as a
Vital Sign
 What is the problem?
-There is a growing prevalence of physical inactivity World-
wide
 Why is this a problem?
- Physical inactivity has a major impact on health
- Being sedentary costs a lot of money
 Association between fitness, mortality and other
health outcomes
 Association between fitness and health care
costs
-What is the impact of being physically active vs. inactive on
health care costs?
- Fitness is strongly associated with health care costs

4. Cardiorespiratory Fitness, Health Outcomes, and
Health Care Costs: The Case for Fitness as a
Vital Sign
 What is the problem?
-There is a growing prevalence of physical inactivity World-
wide

5. Minimal recommendations for physical
activity – WHO, CDC, AHA, ACSM, US
Surgeon General’s Report, IOM, DHSSPS,
European Working Group*
“All individuals should attempt to accumulate 30
minutes of moderate activity on most, if not all,
days of the week”
“Additional health benefits can be gained through
greater amounts of physical activity…”
30 minutes daily activity ≈20 to 40% reductions in
cardiovascular and all-cause morbidity/mortality
*Australia, Canada, Fiji, UK, New Zealand, Germany, Singapore, the Philippines, Switzerland; all are
generally based on the United States Surgeon General’s recommendations for physical activity

6. CDC, 2017
Percentage of adults meeting federal physical activity guidelines
for aerobic and muscle strengthening activities, 1997-2016

7. Wang et al. Lancet 378(9793): 815-825
Growth in World-Wide Prevalence of Overweight/Obesity

8. Percentage of Overweight and Obesity in Europe

9. Ladabaum et al. American Journal of Medicine 2014: 127, 681-684

10. 2018
1990

11. Cardiorespiratory Fitness, Health Outcomes, and
Health Care Costs: The Case for Fitness as a
Vital Sign
 What is the problem?
-There is a growing prevalence of physical inactivity World-
wide
 Why is it a problem?
- Physical inactivity has a major impact on health
 Association between fitness, mortality and other
health outcomes

12. Fitness is a more powerful risk
marker than the traditional
risk factors for CVD and all-
cause mortality

13. Comparison of global burden between smoking and physical inactivity. Prevalence of smoking, population attributable risk
(PAR), and global deaths for smoking were obtained from WHO.
Chi Pang Wen , Xifeng Wu. Stressing harms of physical inactivity to promote exercise. The Lancet Volume 380, Issue 9838
2012 192 - 193

14. 0
2
4
6
8
10
12
14
16
18
Low
CRF*
Obese
Sm
oker
Hypertension
High
Chol
Diabetes
Men
Women
Cooper Aerobics Center Longitudinal Study, 1970-2004. In progress
40,842 Men & 12,943 Women, ACLS
Effect of Fitness (CRF) on Mortality
Attributable Fractions (%) for
All-Cause Deaths
Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009; 43:1-2.

15. Myers J, et al. New Engl J Med 346: 793, 2002
Exercise capacity most powerful predictor of risk
12% reduction in risk per MET

16. 0,00
0,20
0,40
0,60
0,80
1,00
1,20
1 2 3 4 5
RelativeRiskforMortality
Quintiles of Peak VO2 (METs)
5-7 METs
7-9 METs 9-11 METs
>11 METs
(38.5 ml/kg/min)
< 5 METs (17.5 ml/kg/min)
Age-adjusted relative risks for mortality based on peak VO2 among patients referred for
exercise testing for clinical reasons in the Veterans Exercise Testing Study (VETS)
Mortality Rate by Quintiles of Peak VO2 in the VA

17. Relative risks for classification of activity at the time of a
treadmill test among ≈ 7,000 veterans
p for trend <0.001
Myers et al. Am J Med 128: 396-402, 2015
RelativeRisk
Sedentary Minimally Active Moderately Active Active

18. Importance of Assessing Cardiorespiratory Fitness
in Clinical Practice: A Case for Fitness as a Clinical
Vital Sign. A Scientific Statement From the
American Heart Association
Robert Ross, PhD, FAHA, Chair, Steven N. Blair, PED, FAHA, Co-Chair, Ross
Arena, PhD, PT, FAHA,Timothy S. Church, MD, MPH, PhD, Jean-Pierre
Després, PhD, FAHA, Barry A. Franklin, PhD, FAHA, William L. Haskell,
PhD, Leonard A. Kaminsky, PhD, FAHA, Benjamin D. Levine, MD, FAHA,
Carl J. Lavie, Jr, MD, Jonathan Myers, PhD, FAHA, Josef Niebauer, MD,
PhD, MBA, Robert Sallis, MD, Susumu S. Sawada, PhD Xuemei Sui, MD,
MPH, PhD, Ulrik Wisløff, PhD
On behalf of the American Heart Association Physical Activity Committee of
the Council on Lifestyle and Cardiometabolic Health; Council on Clinical
Cardiology; Council on Epidemiology and Prevention; Council on Cardiovascular
and Stroke Nursing; Council on Functional Genomics and
Translational Biology; and Stroke Council
Circulation 134:e653-e699, 2016

19. Cardiorespiratory Fitness, Health Outcomes, and
Health Care Costs: The Case for Fitness as a
Vital Sign
 What is the problem?
-There is a growing prevalence of physical inactivity World-
wide
 Why is it a problem?
- Physical inactivity has a major impact on health
- Being sedentary costs a lot of money
 Association between fitness, mortality and other
health outcomes
 Association between fitness and health care
costs
- What is the impact of being physically active vs. inactive
on health care costs?
- Fitness is strongly associated with health care costs

20. How do you make the connection between health
care costs and being unfit or sedentary?
30 minutes activity/day
≈ 30% reduction in
mortality/cardiac
events
Known cost of MI/
hospitalization
Extrapolation to
health care system
$$ Comparison between
sedentary vs. active
or fit vs. unfit

21. Economic Burden of Physical Inactivity Worldwide
Overall healthcare costs ≈40% lower among “sufficiently active” vs.
insufficiently active subjects with metabolic syndrome.1
Overall 11.1% of health care expenditures attributed to inadequate physical
activity in the US.2
Workplace wellness program saved PepsiCo $1,632 per employee per year,
driven largely by 29% reduction in hospital admissions3
For every euro invested in physical activity there is a €3.21 savings on
medical costs.4
In Australia, for every 1% increase in adult activity levels, there is an
estimated combined savings of nearly €4.26 million in potential treatment
costs for MI, stroke, diabetes, colon cancer, breast cancer and depressive
disorders.5
1) Burton WN et al. The association of self-reported employee physical activity with metabolic syndrome, health
care costs, absenteeism, and presenteeism. J Occup Environ Med 56:919-26, 2014.
2) Carlson et al. Inadequate physical activity and health care expenditures in the United States. Prog Cardiovasc Dis
57:315-323, 2015.
3) Caloyeras JP et al. Managing manifest diseases, but not health risks, saved PepsiCo money over 7 years. Health
Affairs 33:124-131, 2014.
4) World Health Organization. Noncommunicable Diseases And Mental Health Noncommunicable Disease Prevention
And Health Promotion. Health and Development Through Physical Activity and Sport. Geneva 2003
5) World Health Organization / Centers for Disease Control. Collaborating Center on Physical Activity and Health
Promotion, Atlanta, GA 2000.

22. Health care costs and exercise capacity
Weiss JP, Froelicher VF, Myers J, Heidenreich PA.
Chest 126:608-613, 2004
 881 consecutive patients referred for
exercise testing over 2 years
 Costs determined from VA Decision Support
Systems Network (DSS), providing data on
costs, patterns of care, outcomes, and
clinician workload details of specific patient
encounters
 Age-adjusted costs compared for clinical,
historical and exercise test responses

23. 1000
4000
7000
10000
13000
16000
<5 5 to 6.9 7 to 8.9 9 to 10.9 >11
METs
OneYearCost
≈ 6% ↓ in cost per MET
Least fit group ≈ 2x cost of most fit group
Median, 25th and 75th percentiles of health costs for quintiles of fitness

24. Health care costs and exercise capacity
Weiss JP, Froelicher VF, Myers J, Heidenreich PA.
Chest 126:608-613, 2004
Key Points:
 Largest reduction in cost occurred
between the least fit and next least fit
group
 In multivariate analysis adjusting for age,
clinical and demographic variables, and
exercise test results, exercise capacity
was the strongest predictor of costs

25. Association Between Cardiorespiratory Fitness
and Health Care Costs: The Veterans Exercise
Testing Study
Myers J, Doom R, King R, Fonda H, Chan K, Kokkinos P, Rehkopf DH. Mayo Clin Proc 93:48-55, 2018
 9,948 subjects (mean 58.4±11 years) referred for exercise testing for
clinical reasons at the Palo Alto and Washington, DC VA Hospitals
 The VETS cohort is an ongoing, prospective evaluation of veteran
subjects referred for exercise testing for clinical reasons, designed to
address exercise test, clinical, and lifestyle factors and their
association with health outcomes
 Total health care costs derived between 2005 and 2012
 Fitness expressed as percentage of age-predicted peak METs achieved,
categorized in quartiles
<60%; 60-80%; 80-100%; >100%

26. Association between health care costs and exercise capacity

27. MeanTotalCost/Year
(x103)
0
4
8
12
16
20
<60% 60-80% 80-100% >100%
Percentage Age-Predicted Exercise Capacity
Mean health care costs by quartile of fitness
(Total costs per year; USD x 103)
p for trend <0.001

28. MeanCost/Year/Patient
(x103)
Percentage Age-Predicted Exercise Capacity
Mean health care costs by quartile of fitness
(Cost/year/patient; USD x 103)
p for trend <0.001

29. MeanCost/Year/Patient
(x103)
Percentage Age-Predicted Exercise Capacity
 Age-adjusted costs in the least-fit quartile were 35%
higher than subjects in the fittest quartile
 Heart failure was the strongest predictor of health care
costs among clinical variables in the sample, followed by
fitness
 Change in fitness category results in $4,163 annual cost
reduction
 Annual cost reduction of $1,592 per MET achieved (5.4%)
Mean health care costs by quartile of fitness
(Cost/year/patient; USD x 103)
p for trend <0.001

30. 0
20,000
40,000
60,000
0 2.50.5 1.0 1.5 2.0 0 1.5 2.50.5 1.0 2.0 0 1.5 2.50.5 1.0 2.0
BMI <25 kg.m-2 BMI 25-29.9 kg.m-2 BMI ≥30 kg.m-2
de Souza y Silva et al. Association Between Cardiorespiratory Fitness, Obesity, and Health Care Costs:
The Veterans Exercise Testing Study. Submitted, 2018.
Impact of fitness and body mass on healthcare costs

31. Physical Activity Patterns
and Health Care Costs

32. Physical activity patterns and
health care costs in the VA
Health Care System
 Activity patterns quantified among
patients referred for exercise testing
beginning in 1993
 Recreational energy expenditure
(kcals/week) quantified using modified
Harvard Alumni Questionnaire
 Both past (adulthood) and current (last
year) activity patterns assessed
 Costs derived from the VA Decision
Support Systems Network

33. 3.9±0.07
4±0.07
4.3±0.07*
3.6
3.7
3.8
3.9
4
4.1
4.2
4.3
4.4
LogofTotalHealthCareCosts
Active Moderately Active Inactive
Recreational Activity Status
* p <0.05 vs. moderately active and active
10% cost difference active vs. inactive
≈ $1 reduction per kcal/week
3.9±0.07
4.0±0.07
4.3±0.07*

34. Cost of inactivity in the Palo Alto VA Health
Care System
 Assuming $1 saved per kcal expended/week
 Meeting the minimal recommendations for activity
(30 min/day ≈ 1000 kcal/week) amounts to $50,000
in cost savings/year
 30% of patients seen in Cardiology report no
physical activity; another third doesn’t meet the
minimal recommendations
 15,000 patients seen/year in the Cardiology clinics
 If these sedentary patients walked 30 min/day, $50
million would be saved

35. Summary
 Higher fitness is associated with significantly lower
overall health care costs
 Age-adjusted costs in the least-fit quartile are 30-
50% higher than subjects in the fittest quartile
 Annual cost reduction per patient of $1,592 per MET
achieved
 Cost savings with higher fitness are more evident in
overweight and obese subjects
 Fitness is a strong predictor of health care costs
 There is a growing body of objective, economic-based
evidence for employers, health care professionals,
and professional organizations to promote physical
activity

37. GO BACK!!! GO BACK!!!
We Really Screwed Up!