Combined association of aerobic and muscle strengthening activity with mortality in individuals with hypertension

Physical activity (PA) improves health and reduces mortality risk, and adult guidelines recommend at least 500 MET-min/week of aerobic PA plus moderate- or high-intensity muscle-strengthening activity (MSA) targeting all major muscle groups on at least two days per week. Despite these recommendations, most adults do not meet both components. Hypertension is a major global cause of morbidity and mortality, and recommendations for hypertensive individuals mirror general PA guidelines. While aerobic PA and MSA each have been linked to lower mortality and combined training is effective for blood pressure management, evidence on the combined effect of simultaneously meeting aerobic and MSA guidelines on mortality—particularly stratified by hypertension status—remains limited. This study aimed to examine how hypertension status and adherence to PA guidelines (aerobic, MSA, both, or neither) are associated with all-cause and cardiovascular disease (CVD) mortality.

The paper situates the study within evidence that: (1) a large proportion of adults worldwide do not meet aerobic PA guidelines and over 80% do not meet both aerobic and MSA recommendations; (2) prior public health research has emphasized aerobic PA benefits while giving less attention to MSA and combined adherence; (3) combined aerobic and resistance training benefits blood pressure control; (4) studies in hypertensive populations show inverse dose–response relationships of aerobic PA and MSA separately with mortality, but data on their combined impact are scarce; and (5) it is unclear whether associations differ by hypertension status. These gaps motivate evaluating combined adherence to both PA components in relation to mortality in hypertensive versus non-hypertensive adults.

Design and data source: Prospective cohort analysis using the nationally representative Korea National Health and Nutrition Examination Survey (KNHANES) from 2007–2013, with mortality linkage through December 31, 2019. Population: Adults aged ≥19 years with available blood pressure (BP), physical activity (PA) data, and mortality linkage. Exclusions: self-reported prevalent CVD (angina pectoris, myocardial infarction, stroke) and cancer; missing/invalid PA data; missing BP or antihypertensive medication data; missing covariates; and deaths within the first year of follow-up to reduce reverse causality. Final analytic sample: 34,990. Hypertension assessment: BP measured by trained staff with mercury sphygmomanometers after a 5-minute seated rest; three measurements at 30-second intervals; mean of the second and third used for systolic and diastolic BP. Quality control adjustment was applied to 2008–2010 BP values due to identified arm height issues. Hypertension defined as systolic BP ≥140 mmHg, diastolic BP ≥90 mmHg, or self-reported antihypertensive medication use. Physical activity assessment: Self-reported using items adapted from the International Physical Activity Questionnaire on frequency and duration (≥10 minutes/session) of vigorous, moderate PA, and walking in the past week. MET values assigned: vigorous 8, moderate 4, walking 3.3. Total aerobic PA calculated as MET-min/week by summing intensity × frequency × duration across activities. MSA assessed as days/week of participation in activities such as push-ups, sit-ups, and weight lifting. Guideline adherence categories: (1) Neither: aerobic <500 MET-min/week and MSA <2 days/week; (2) MSA only: aerobic <500 and MSA ≥2 days/week; (3) Aerobic only: aerobic ≥500 and MSA <2 days/week; (4) Both: aerobic ≥500 and MSA ≥2 days/week. Mortality outcomes: Vital status and causes of death obtained by linkage of KNHANES to national Cause of Death Statistics. CVD mortality defined using ICD-10 codes I00–I99. Follow-up through 2019. Covariates: Baseline age, sex, household income (low, low-middle, middle-high, high), education (<elementary, middle, high school, ≥college), marital status (unmarried, widowed/divorced, married), smoking (never, former, current), alcohol consumption (non-heavy vs heavy; heavy defined as ≥7 drinks at least twice/week for men, ≥5 for women), BMI (kg/m²), diabetes (fasting glucose ≥126 mg/dL, medication use, or physician diagnosis), and dyslipidemia (total cholesterol ≥240 mg/dL, LDL-C ≥160 mg/dL, HDL-C <40 mg/dL, triglycerides ≥200 mg/dL, or lipid-lowering medication use). Statistical analysis: Baseline characteristics summarized by hypertension status and PA guideline adherence. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and CVD mortality. Proportional hazards assumption checked via log plots. Models: Model 1 adjusted for age and sex; Model 2 additionally adjusted for income, education, marital status, smoking, alcohol, BMI, diabetes, and dyslipidemia; Model 3 additionally mutually adjusted for hypertension status and PA to estimate independent associations. Subgroup analyses assessed whether associations between PA adherence and mortality differed by hypertension status. Joint (cross-classified) analyses created 8 categories combining hypertension status with the 4 PA adherence levels; multiplicative interaction tested via log-likelihood ratio tests. Sensitivity analyses excluded deaths within an additional two years and stratified hypertensive participants by antihypertensive medication use. Analyses performed in R 4.2.0; two-sided P<0.05 considered statistically significant.

• Cohort size and events: 34,990 adults; mean follow-up 9.2 years; 1,948 all-cause deaths and 419 CVD deaths.
• Hypertension associated with higher mortality: vs non-hypertensive, HR 1.11 (95% CI 1.01–1.22) for all-cause; HR 1.40 (95% CI 1.14–1.73) for CVD mortality.
• Aerobic PA dose: compared with 0 MET-min/week, ≥1000 MET-min/week associated with lower mortality: all-cause HR 0.82 (95% CI 0.72–0.93); CVD HR 0.67 (95% CI 0.52–0.87).
• MSA frequency and all-cause mortality: 1 day/week HR 0.65 (95% CI 0.47–0.90); 2–3 days/week HR 0.73 (95% CI 0.59–0.89) vs none.
• PA guideline adherence patterns: • Meeting both aerobic and MSA guidelines was associated with the lowest risks of all-cause and CVD mortality in the total sample, regardless of hypertension status. • Among individuals with hypertension: meeting aerobic guidelines only was associated with approximately 24% lower risk for both all-cause and CVD mortality; meeting both guidelines further reduced risk by about 40% for all-cause and 43% for CVD mortality. Meeting MSA-only guidelines was not associated with reduced all-cause or CVD mortality. • Among individuals without hypertension: only meeting both guidelines (aerobic + MSA) was associated with reduced CVD mortality; meeting either guideline alone (aerobic or MSA) was not associated with reduced CVD mortality.

The study directly addresses whether, and to what extent, meeting aerobic PA and MSA guidelines—alone or in combination—relates to mortality risk in adults with and without hypertension. Findings indicate that the combined adherence to both PA components yields the greatest survival benefit. In hypertensive individuals, engaging in aerobic PA confers meaningful reductions in both all-cause and CVD mortality, and concurrent MSA with aerobic PA provides additional benefit; however, MSA alone does not reduce mortality risk. In non-hypertensive individuals, reductions in CVD mortality were evident primarily when both components were met together. These results support current recommendations emphasizing both aerobic and muscle-strengthening activities and suggest prioritizing aerobic PA for hypertensive adults while promoting combined training for maximal benefit. The results are clinically relevant in the context of hypertension as a leading cause of premature death and underscore the potential for meeting minimal PA guideline thresholds to offset some of the associated risk. The patterns observed also have implications for Asian populations, reinforcing the importance of concurrently implementing aerobic and strength activities in public health strategies.

In a large, nationally representative Korean cohort, meeting both aerobic and MSA guidelines was associated with the lowest risk of all-cause and CVD mortality, with particularly strong benefits among individuals with hypertension. Aerobic PA alone reduced mortality in hypertensive adults, while MSA alone did not. In non-hypertensive adults, mortality benefits—especially for CVD—were most evident when both guidelines were met. These findings support emphasizing combined adherence to aerobic and muscle-strengthening guidelines in hypertension management and public health recommendations. Future research should determine optimal MSA dosage and patterns for hypertensive populations to maximize survival benefits and clarify causal mechanisms.

• Physical activity was self-reported, introducing potential recall and misclassification bias for both aerobic PA and MSA frequency.
• Observational design limits causal inference; residual confounding may persist despite multivariable adjustment.
• Although early deaths (first year) were excluded and additional sensitivity analyses were conducted (excluding deaths within two more years), reverse causation cannot be fully ruled out.
• BP definitions and measurements may have measurement error despite standardized protocols and adjustments to 2008–2010 values.
• Generalizability may be most applicable to Korean/Asian populations; results may differ in other populations or healthcare contexts.
• Limited detail on MSA intensity, volume, and specific modalities prevents precise dose–response characterization for strength training.