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Abstract

The mortality rate from ischemic heart disease (IHD) is increasing in both developed and developing countries. The US guidelines for physical activity are known to reduce the risk of IHD; however, no literature review has verified this. This meta-analysis aimed to examine the protective effect of adhering to the US guidelines for physical activity on the IHD risk based on the types of exercise. Six databases, including MEDLINE, EMBASE, Cochrane Library, CINAHL, Scopus, and Web of Science, were searched from January 1, 2000, to November 6, 2022. The literature search was performed on November 6, 2022, at the latest. Only studies designed and conducted in English focusing on IHD-related physical activities in humans were included. The main outcomes were the heterogeneity of studies, overall effects of all types of physical activity, and IHD risk. The random effects model was measured, and a funnel plot was used to examine for publication bias. When the US guidelines for physical activity were not applied, a high level of heterogeneity was found in the effects of physical activity based on its type, with overall effects of 0.764 (odds ratio [OR], 95% confidence interval [CI] [0.737, 0.795]). The effect of physical activity on IHD was 0.593 (OR, 95% CI [0.489, 0.720]). No publication bias was observed. After applying US guidelines for physical activity, a low level of heterogeneity was found in its effects, and the observed OR for myocardial infarction was 0.515 (95% CI [0.401, 0.662]). Each type of exercise had different effects on reducing IHD, and certain beneficial results were observed if US guidelines for physical activity were met.

Plain language summary

Heart-related diseases are a leading cause of death around the world, affecting people in both wealthy and less wealthy countries. Experts have long suggested that exercise helps lower the risk of these diseases, and the United States has developed specific exercise guidelines to improve heart health. Until now, there hasn’t been a thorough review confirming whether these guidelines are actually effective. Our study has filled this gap by carefully examining the impact of following the US exercise guidelines on heart disease, particularly looking at how different types and intensities of exercise can prevent heart problems. We found that sticking to these guidelines really does make a difference. Not only does it lower the risk of heart disease, but it also brings consistency to the results of various studies, suggesting that it’s not just the kind of exercise you do, but also how long and how intensely you do it that counts. This is more than just good news for individuals; it has significant implications for public health as a whole. Our research supports the idea that governments and health organizations should encourage people to follow these exercise guidelines to keep their hearts healthy. By doing so, we can help prevent new cases of heart disease and avoid the worst outcomes, like heart attacks. In short, our study shows that moving more, in the right ways, can lead to healthier hearts across the population.

Keywords

physical activity ischemic heart disease guidelines systematic review as a topic health policy

Introduction

Ischemic heart disease (IHD) is the leading cause of death worldwide (Moran, 2018). Every year, one-third of deaths worldwide are caused by IHD (Moran, 2018). Previously, IHD was the most serious health issue and the leading cause of death in older adults (Mayo Clinic, 2021). However, these diseases are currently not restricted to older adults (Dong et al., 2022). IHD symptoms include tachycardia, fainting during exercise, sweating, and fatigue, with the most common being chest pain and light-headedness (Mayo Clinic, 2021). Exercising can result in up to a three-fold IHD risk reduction (Fiuza-Luces et al., 2018; World Health Organization, 2022a). Participants who engage in physical activity for more than 12 hr a week reportedly have lower mortality rates than those who engage in physical activity for less than 12 hr a week (Luksiene et al., 2023). Moreover, exercise-based intervention in ischemic threshold reportedly has a 1.5-fold improvement compared to that in participants who do not exercise (Lara Vargas et al., 2022). The metabolic equivalent (MET) method is commonly used to estimate exercise intensity (Jetté et al., 1990) and can also calculate the exercise duration. Moreover, the types of exercise are also important in reducing the risk of IHD (Sesso et al., 1999). Several factors have led many governments to encourage regular physical activities (Ahrens, 2020; Centers for Disease Control and Prevention, 2022a). For example, the US guidelines for physical activities suggest 150 min of moderate-level exercise or 75 min of weightlifting (Centers for Disease Control and Prevention, 2022b). There have been many attempts to prove the validity of the US guidelines to the public. Many studies have demonstrated that the US guidelines effectively improve public health in the general population (Arias-Palencia et al., 2015; Carnethon, 2009; Pate et al., 2002; US Department of Health and Human Services, 2022; Weed, 2016). However, people usually think about the kind of exercise to engage in rather than its duration. The US guidelines for physical activity are similar to the World Health Organization (WHO) guidelines published in 2020 (World Health Organization, 2020). The US guidelines for physical activity suggest performing 150 min of moderate-intensity or 75 min of vigorous-intensity physical activity per week, and they recommend two sessions of muscle strengthening activity in 1 week (Teixeira et al., 2012). The WHO guideline suggests 150 to 300 min of moderate-intensity or 75 to 150 min of vigorous-intensity aerobic physical activity per week (or more than 300 min of moderate-intensity aerobic physical activity or 150 min of vigorous-intensity activity for additional benefits), and it recommends two sessions of muscle strengthening activity per week (World Health Organization, 2020). However, the US guidelines have utilized the key doctrine of “Move Your Way” in the US; this became popular, and several analyses have been conducted on its effects and effectiveness on public health in the US (World Health Organization, 2022b). Previous meta-analyses have been conducted to determine the levels of exercise-based interventions that affect the IHD risk (Ekelund et al., 2019).

The objectives of this study are two-fold. First, this study aimed to examine the protective effect of adhering to the US guidelines for physical activity on the IHD risk. Second, a meta-analysis was performed to validate the US guidelines and determine which types of exercise are relatively efficient.

Methods

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Search Strategy and Eligibility Criteria

In this meta-analysis, six databases, including MEDLINE, EMBASE, Cochrane Library, CINAHL, Scopus, and Web of Science, were searched from January 1, 2000 to November 9, 2022. The literature search was conducted on November 9, 2022 at the latest, and only English articles were included. The Population, Intervention, Control, and Outcomes (PICO) method was used to define study characteristics.

The delineation of the inclusion criteria was based on the PICO method as follows: encompassing the population as the general populace, the intervention being participants in alignment with the US guidelines for physical activity, the comparison involving individuals not in conformity with the aforementioned guidelines, and the outcome pertaining to the mitigation of IHD risk. Primarily, articles examining forms of physical activity within the purview of observational study designs were included in the analysis. The exclusion criteria were as follows: (1) a publication dated before 2000, (2) manuscripts not written in English, (3) studies not of primary nature, (4) articles diverging from the classification of research articles, (5) inquiries not centered on the exploration of distinct varieties of physical activity, and (6) investigations not germane to the established PICO criteria. Two authors (J.K and K.H) independently extracted the data, and consensus was reached through discussion with the corresponding author (J.C).

Inclusion Criteria

Study design: Observational studies (cohort, case-control, cross-sectional) examining physical activity and ischemic heart disease risk.

Population: Adult participants (≥18 years) of any gender or ethnicity.

Intervention/exposure: Varied forms of physical activity, including walking, running, swimming, cycling, and strength training.

Outcome measures: Incidence or risk of ischemic heart disease with clearly defined outcomes (myocardial infarction, coronary artery disease).

Language and publication date: Articles in English published from January 2000 to November 2022.

Exclusion Criteria

Study design: Exclusion of randomized controlled trials, reviews, editorials, commentaries, and animal studies.

Population: Studies focusing on specific conditions other than ischemic heart disease.

Incomplete data: Exclusion of studies with insufficient physical activity data or missing outcome information.

Quality assessment: Studies scoring poorly on the Newcastle-Ottawa Scale for observational studies.

In our analysis, we focused on studies that enabled ascertainment of both the aerobic physical activity and muscle strengthening components of the US physical activity guidelines. We established the criteria based on the US guidelines for physical activity. We excluded a study if its level of physical activity failed to meet the requirements set by the US guidelines, even if it assessed the dose-response relationship between physical activity and IHD risk. In such instances, we conducted a thorough evaluation to determine whether the reported levels of physical activity aligned with the recommendations outlined in the US guidelines despite this approach potentially underestimating the impact of physical activity levels falling below the US guideline recommendations. We aimed to include research that covered both these components comprehensively to provide a thorough assessment of their impact on IHD risk.

Data Extraction and Quality Assessment

After the first title/abstract screening was performed using Microsoft Excel, data were collected through full-length paper reviews (Microsoft Corporation, 2018). Two authors independently assessed the studies and discussed with the corresponding author if differences were observed. Quality assessment was conducted using the Newcastle–Ottawa Scale (NOS), commonly utilized for non-randomized controlled trials (The Ottawa Hospital Research Institute, 2022). Two authors independently assessed the studies extracted and discussed with the corresponding author if differences were observed. We justified the selection of the study period from 2000 to 2022 in the Introduction. This period was chosen due to significant advancements in activity guidelines and monitoring technologies, providing a relevant dataset for analysis. This timeframe also ensures a comprehensive capture of data post the proliferation of digital health records and advanced biometric devices.

Variables

In the realm of epidemiological research, the veracity of associations observed between physical activity and ischemic heart disease (IHD) risk can be obscured by various confounding factors. This study diligently acknowledges and addresses three primary confounders: dietary habits, genetic predisposition, and socio-economic status, each of which may independently or synergistically influence the risk of IHD.

Dietary habits: Recognizing the intricate interplay between diet and cardiovascular health, this study meticulously selected research that accounted for dietary patterns. The influence of nutrition on the efficacy of physical activity in mitigating IHD risk is well-established; hence, the inclusion criteria for the selected studies mandated the adjustment for dietary variables. This careful selection ensures that the protective effects of physical activity, as delineated in our findings, are not confounded by dietary influences, thus providing a more accurate reflection of the true impact of exercise on IHD risk.

Genetic predisposition: The genetic underpinnings of IHD are complex and multifactorial. To nullify the potential distortion of results by genetic variability, this meta-analysis incorporated studies that corrected for genetic predispositions. This adjustment permits a clearer interpretation of the data, isolating the role of physical activity from hereditary influences and reinforcing the validity of the association between adherence to physical activity guidelines and IHD risk reduction.

Socio-economic status: Socio-economic status is a known determinant of health outcomes, influencing both lifestyle choices and access to healthcare resources. In our selection process, we emphasized studies that controlled for socio-economic variables, ensuring that the outcomes are not confounded by disparities in income, education, or access to healthcare. By doing so, the study furnishes a more equitable assessment of the relationship between physical activity and IHD risk, transcending socio-economic barriers.

In summation, the deliberate consideration and requisite adjustment for these confounding factors in our study selection criteria enrich the rigor and credibility of our analysis. The findings from literature with careful consideration herein are thus reflective of a careful and methodical approach to elucidate the true relationship between physical activity and IHD, enhancing the strength and applicability of our conclusions.

Outcomes

The ongoing debate about the effects of IHD, mainly due to injury characteristics, is well-documented in recent cardiology research. In the primary analysis, the types of exercise and IHD risk were assessed; the hazard ratio (HR) was calculated without considering the guidelines for physical activity. In the secondary analysis, the US guidelines for physical activity were considered, and the IHD risk was determined for activities that adhered to the recommendation of engaging in at least 150 min of moderate and vigorous physical activity per week, accompanied by two sessions of muscle strengthening activities per week, as stipulated by the US guidelines for physical activity. Subsequently, the HR was compared between the overall and guideline-applied physical activity outcomes.

Physical Activity

The study has refined its classification of physical activities, now considering both type and introducing measures of intensity (low, moderate, high) and frequency (daily, weekly, monthly). This enhanced classification offers a more precise understanding of physical activity’s multifaceted nature and its influence on Ischemic Heart Disease (IHD) risk.

We believe this refined classification will foster a more comprehensive understanding of how different forms and levels of physical activity contribute to cardiovascular health and IHD prevention. By acknowledging the complexity of physical activity behaviors, our study underscores its potential in mitigating IHD risk. The “Exercise Volume” formula, encompassing Time, Intensity, Frequency, and Type (Anderson & Durstine, 2019), serves as the theoretical foundation, well-supported by exercise physiology research and its health implications.

Our study primarily focuses on the United States due to several reasons. Firstly, the World Health Organization (WHO) and the American Heart Association (AHA) guidelines provide a robust evidence base for cardiovascular health and physical activity, with a significant portion of the available research data originating from studies conducted in the US. Additionally, considering the variability in physical activity recommendations across different countries, it was necessary to establish a specific geographical context to ensure the consistency and applicability of our findings.

While our research draws heavily from US-based studies, we acknowledge the importance of considering international perspectives and guidelines in future work. Expanding our research to encompass a broader geographical scope may offer valuable insights into the global variations in physical activity and its impact on cardiovascular health. This approach would contribute to a more comprehensive understanding of the subject and its applicability across diverse populations and healthcare systems.

Data Analysis

We measured results by assessing the odds ratio (OR) and 95% confidence intervals (CIs) of the studies. These standards were applied to both categorical and numerical values. A random-effect model was employed to analyze the results of a comprehensive search. The obvious and statistical analyses of the meta-analysis were estimated using the I ² statistics method (von Hippel, 2015). After the data analysis, a funnel plot was used to examine publication bias, which is a major bias in systematic reviews/meta-analyses (Sterne et al., 2011). Meta-analysis was performed using R Studio (RStudio Team RStudio, 2020). Participants in each study were categorized based on their level of physical activity (both overall and those adhering to the guideline); the results of all studies were age- and sex-standardized.

Equality, Diversity, and Inclusion (EDI) Statement

Commitment to diversity and equality: In this research, we steadfastly recognize and embrace the importance of diversity and equality. Our approach is informed by the understanding that cultural and national contexts significantly influence the research subject, in this case, physical activity and its relation to ischemic heart disease.

Diverse geographical representation: The studies included in our meta-analysis represent a broad geographical spectrum, with significant contributions from the United States (referencing Bennie et al., 2019), Finland (referencing Hu et al., 2007), and Sweden (referencing Fransson et al., 2004). This selection underlines our commitment to incorporating diverse perspectives and contexts, acknowledging that lifestyle, cultural attitudes towards physical activity, and healthcare access vary markedly across different regions.

Cultural nuances in physical activity: We acknowledge that factors such as dietary habits, work-life balance, and recreational activities are not uniform across cultures and geographies. These variations play a crucial role in determining physical activity levels and, by extension, the risk of ischemic heart disease. For instance, the prevalence of active commuting in Finnish culture may influence physical activity levels differently than the more recreational or structured exercise routines common in the United States.

Healthcare accessibility and quality: The research also considers the variability in healthcare services, particularly in terms of accessibility and quality across different countries. These differences are vital in understanding how physical activity relates to the detection, management, and prevention of ischemic heart disease.

Implications for future research: We strongly advocate for the incorporation of diverse population samples in future research. This commitment not only enhances the understanding of the relationship between physical activity and ischemic heart disease but also ensures that our findings are applicable and relevant on a global scale.

Results

Study Population and Selection

The literature search resulted in 7,612 articles after eliminating duplicates. Only 270 studies satisfied the inclusion and exclusion criteria regarding their titles and abstracts. We extracted the full text of 270 papers; however, only seven studies were included in the final analysis. The studies were excluded if they were based on the wrong study population (14 studies) or did not assess the types of exercise according to IHD outcomes. The selected articles exhibited a limited scope of research, raising potential concerns about bias due to this confined focus. Our selection process meticulously targeted literature concerning various types of physical activity and their association with the IHD risk within the general population. Notably, the collective participation of 588,030 individuals was observed across the chosen studies (Figure 1).

Figure 1.

Study flow chart.

Literature Review

Bennie et al. (2019): This cohort study was conducted in the US in 2019; the exercise types were aerobics, weight training, and mixed exercise according to the US guidelines for physical activity. The target diseases were hypertension, myocardial infarction (MI), high cholesterol, stroke, and coronary heart disease (CHD). This study aimed to demonstrate the effect of the combined moderate to vigorous physical activity and muscle strengthening activity guidelines on a sample of adults from the US. The expected risk of bias was a recall bias because it was a self-report study (Table 1).

Table 1.

Literature Review of Studies (Sample Size: Total 588,030 of the General Population).

Study no.	Authors	Date	Study design	Types of exercise	Target disease	Country	Objectives
1	Bennie et al.	2019	Cohort study	Aerobics, weight training, and mixed	Hypertension, MI, high cholesterol, stroke, CHD	USA	To demonstrate the combined MVPA and MSA guidelines’ effect on the sampled adults from the US.
2	Tanasescu et al.	2002	Cohort study	Running, jogging, rowing, cycling, swimming, and racket sports	CHD/	USA	To explore the type, intensity, and amount of exercise in relation to the risk of coronary heart disease in men
3	Hu et al.	2020	Cohort study	Occupational exercise, walking or cycling to and from work, and LTPA	CHD	Finland	To prove associations of types of physical activity with a decade risk of CHD based on the FRS
4	Lovasi et al.	2007	Case-control study	Walking, gardening, exercise cycling, bowling, calisthenics, exercise machines, dancing, golfing, weight training, swimming, aerobics, and hiking	MI	USA	To investigate the association between the amount of LTPA and the reduction of MI risk.
5	Chomistek et al.	2016	Cohort study	Jogging, running, bicycling, swimming, and tennis	CHD	USA	To assess the association between the volume of LTPA measured based on MET-hours/week.
6	Porter et al.	2019	Cohort study	Aerobics, basketball, bicycling, calisthenics, golf walking, racket sports, running, swimming, walking, and weight training	Cardiovascular disease	USA	To examine the relationships of participation in the types of exercise and incident myocardial ischemia.
7	Fransson et al.	2004	Cohort study	Repetitive lifting at work, heavy lifting at work, and household work	MI	Sweden	To estimate the household work, exercise, and occupational physical activity and risk of acute MI relatively. Potential interaction of physical activity examined.

Note. CHD = coronary heart disease; FRS = Framingham risk score; LTPA = leisure-time physical activity; MET = metabolic equivalent of task; MI = myocardial infarction; MVPA = moderate to vigorous physical activity; MSA = muscle strengthening activity.

Tanasescu et al. (2002): This cohort study was conducted in 2002 in the US. The types of exercises were running, jogging, rowing, cycling, swimming, and racket sports. The target disease was CHD. The study aimed to explore the type, intensity, and amount of exercise with respect to the risk of CHD in men. The expected risk of bias was misclassification bias because it was a self-report study.

Hu et al. (2007): This was a cohort study conducted in Finland in 2020. The types of exercises were occupational exercise, walking or cycling to and from work, and Leisure-Time Physical Activity (LTPA), and the target disease was CHD. The study aimed to prove the association of types of physical activity with a decade risk of MI based on the Framingham risk score. The expected risk of bias was a recall bias because it was a self-report study.

Lovasi et al. (2007): This cohort study was conducted in 2007, and the types of exercise were walking, gardening, exercise cycling, bowling, calisthenics, exercise machines, dancing, golfing, weight training, swimming, aerobics, and hiking. The target disease was MI. The study aimed to investigate the association between the amount of LTPA and the reduction of MI risk. The expected risk of bias was a recall bias because it was a self-report study.

Chomistek et al. (2016): This cohort study was conducted in 2016 in the US. The types of exercise considered were walking, gardening, cycling, bowling, calisthenics, exercise machines, dancing, golfing, weight training, swimming, aerobics, and hiking. The target disease was MI. The study aimed to investigate the association between the amount of LTPA and MI risk reduction. The expected risk of bias was a recall bias because it was a self-report study. The authors also mentioned that there could also be an underestimation of the association with MI risk for survivors.

Porter et al. (2019): This cohort study was conducted in 2019 in the US. The exercises considered were aerobics, basketball, bicycling, calisthenics, golf walking, racket sports, running, swimming, walking, and weight training. The target disease was MI. The study assessed the association between the volume of LTPA measured based on the MET-hour/week. The expected risk of bias was a recall bias because it was a self-report study.

Fransson et al. (2004): This cohort study was conducted in 2004 in Sweden. The types of exercise were repetitive lifting at work, heavy lifting at work, and household work. The target disease was MI, and the study examined the relationship between participation in the types of exercise and incidents of MI. The expected risk of bias was reporting and misclassification bias because it was a self-report study.

Quality Assessment

The NOS was utilized to assess the quality of the selected studies.

Study Outcomes

Concerning the types of exercise that satisfied the US guidelines for physical activity, there were 11, 6, and 4 values for aerobics, lifting, and mixed exercises, respectively. Regarding the physical activity details, there were four, one, one, two, one, one, one, one, three, one, one, and one value for aerobics, dancing, hiking, swimming, basketball, running, calisthenics, exercise machines, weight training, biking, bowling, and mixed exercises, respectively.

The study design analysis included 9 and 12 values for case-control and cohort studies, respectively. Target diseases had 12 values for MI; four for IHD, heart failure, or stroke; three for MI; and two for stroke. Trim and fill analysis and a funnel plot analysis were performed to assess publication bias; in our meta-analysis, the funnel plot exhibits a symmetrical inverted funnel shape, indicative of minimal publication bias. This symmetry suggests that both smaller and larger studies are evenly distributed around the overall effect size. Furthermore, statistical tests for publication bias, such as Egger’s test, corroborate this visual assessment, showing no significant evidence of bias. Therefore, the combined visual and statistical analysis of the funnel plot supports the conclusion that our meta-analysis is not influenced by publication bias (Supplementary Table 1).

Primary Outcomes

Regarding the heterogeneity of studies, 96.1% of the included studies had a significantly high level of heterogeneity when the random effects model was used. The overall effect of types of physical activity on IHD was OR: 0.744 (95% CI [0.740, 0.748]). The ORs for the standards used were 0.813 (95% CI [0.779, 0.849]), 0.917 (95% CI [0.823, 1.023]), and 0.681 (95% CI [0.637, 0.727]) for aerobics, weight training, and mixed exercises, respectively. Regarding the target disease, the ORs were 0.752 (95% CI [0.647, 0.875]), 0.819 (95% CI [0.716, 0.938]), 0.703 (95% CI [0.634, 0.779]), 0.788 (95% CI [0.751, 0.826]), 0.788 (95% CI [0.715, 0.869]), and 0.846 (95% CI [0.788, 0.909]) for hypertension, high cholesterol, MI, IHD, stroke, and heart failure, respectively. Across countries, the ORs for studies in the US, Finland, and Sweden were 0.773 (95% CI [0.742, 0.805]), 0.702 (95% CI [0.619, 0.797]), and 0.779 (95% CI [0.678, 0.896]), respectively (Figure 2). The funnel plot and trim and fill analysis showed no publication bias (Supplementary Figure 1).

Figure 2.

Forest plot generated based on types of exercise.

Secondary Outcomes

Regarding heterogeneity of the studies, 16.1% of them showed heterogeneity. OR was divided into three categories, namely, aerobics, weight training, and mixed exercises. The OR of aerobics, weight training, and mixed exercises were 0.607 (95% CI [0.469, 0.787]), 0.569 (95% CI [0.388, 0.833]), and 0.585 (95% CI [0.370, 0.924]), respectively (Figure 3).

Figure 3.

Forest plot generated by standard satisfaction.

To target the disease, OR was divided into three categories, including CHD, MI, and stroke. The ORs for targeting CHD, MI, and stroke were 0.515 (95% CI [0.401, 0.662]), 0.777 (95% CI [0.540, 1.116]), and 0.630 (95% CI [0.356, 1.114]), respectively (Figure 4).

Figure 4.

Forest plot generated based on target disease from studies that satisfied US guidelines.

For study designs, the ORs for case-control and cohort studies were 0.503 (95% CI [0.383, 0.661]) and 0.703 (95% CI [0.533, 0.927]), respectively. When exercises were included in the model, the ORs were 0.503 (95% CI [0.383, 0.661]), 0.733 (95% CI [0.444, 1.212]), 0.880 (95% CI [0.341, 2.272]), 0.680 (95% CI [0.327, 1.415]), 1.000 (95% CI [0.340, 2.939]), 0.738 (95% CI [0.384, 1.421]), and 0.540 (95% CI [0.301, 0.968]) for LTPA, aerobics, basketball, running, swimming, weight training, and mixed exercises, respectively.

Discussion

Our study showed that aerobics and weight training have beneficial effects on IHD. Without the US guidelines for physical activity, there is a high level of heterogeneity in the effects of physical activity based on type, with overall effects of 0.764 (OR; 95% CI [0.737, 0.795]). No publication bias was observed. However, after applying the US guidelines for physical activity, there was not only a low level of heterogeneity in its effects but also an observed OR of 0.515 (95% CI [0.401, 0.662]) in MI. The significant reduction in the heterogeneity of studies suggests that certain levels of exercise intensity should be recommended and that the duration of exercise should be included irrespective of the types of exercise. No significant difference was found between countries. This study acknowledges the reliance on self-reported data and the associated risks of recall and misclassification biases, which could compromise the reliability of our findings. To address these concerns, we have incorporated measured outcomes obtained through medical instrumentation, thereby enhancing the empirical robustness of our conclusions we concentrate on methodologies implemented to attenuate recall bias, drawing upon the exemplary research conducted by Fransson et al. (2004) and Tanasescu et al. (2002). These studies are paradigmatic in demonstrating methodological excellence in the collection of physical activity data. Fransson et al. (2004) utilized structured questionnaires coupled with comprehensive follow-up interviews, a strategy aimed at enhancing the accuracy of the data collected. This meticulous approach ensures a more precise recollection of physical activity levels among participants, thereby effectively minimizing recall bias.

In a similar vein, Tanasescu et al. (2002) adopted a method of collecting physical activity data at multiple points over time within their study. This prospective approach allows for a dynamic assessment of physical activity, with the added benefit of cross-validating data points to diminish inaccuracies stemming from recall. Our meta-analysis emphasizes the critical importance of employing robust data collection methods in physical activity research. The integration of objective measures, such as accelerometers or pedometers, in conjunction with self-reported data is advocated to enhance the reliability of the findings. Such a multifaceted approach not only fortifies the credibility of our research outcomes but also marks a significant contribution to the evolution of methodological practices in the realm of physical activity research. Increased physical activity was reportedly associated with lower blood pressure in individuals with hypertension, increased high-density lipoprotein cholesterol levels in a dose-response manner, and reduced incidence of diabetes (Kessler, 2000). The health benefits of physical activity can be achieved by engaging in moderate-intensity physical activity (such as brisk walking) for at least 30 min per day, 5 days per week, or vigorous activity (such as jogging) for 20 or more minutes, 3 days per week. Combinations of the two types of activity can also be performed. Additionally, in a Mendelian randomization study, authors reported that genetically predicted self-reported vigorous physical activity was significantly associated with a lower risk of MI (OR: 0.24, 95% CI [0.08, 0.68], p-value: .007) (Sesso et al., 2000). Furthermore, those results were consistent after the sensitivity analysis. The INTERHEART study demonstrated that regular exercise reduces the risk of MI (OR: 0.86) (Lee et al., 2003). Another study, which followed 84,129 women who engaged in moderate or vigorous exercise for over 30 min per day, reported a relative risk of 0.17 (Yusuf et al., 2004). In this systematic review and meta-analysis, we explored the connection between various types of physical activity and ischemic heart disease (IHD) risk, in line with US guidelines. Our study enriches the ongoing health and medical sciences dialogue, similar to Martinez-Narro et al.’s (2023) oral cancer research, Gasperini et al.’s (2023) study on plastic waste pyrolysis, and Saeed et al.’s (2022) work on photo biomodulation in surgeries. These studies, like ours, employ systematic literature review and data synthesis techniques.

However, uniquely focuses on physical activity’s role in IHD prevention, a major public health concern. This approach differs from the more specialized focuses of the compared studies and has broader public health ramifications. Our findings are particularly relevant to IHD prevention strategies and guidelines, a significant global health issue. A key aspect of our study is its grounding in US physical activity guidelines, enhancing its applicability to current health practices and emphasizing the importance of guideline-informed research in public health. This contrasts with the other studies’ focus on clinical efficacy and environmental sustainability, which, while rigorous, don’t primarily center on guideline-based analysis. Methodologically, our meta-analysis of epidemiological data differs from the bibliometric methods used in the oral cancer trend analysis, demonstrating varied approaches within health and medical sciences. Therefore, our study stands out in the systematic review and meta-analysis landscape by tackling a vital public health issue. It contributes to the growing body of evidence supporting physical activity’s preventive role.

In this meta-analysis, we have meticulously delineated the inclusion and exclusion criteria, focusing on the types and nature of physical activities. This approach is inspired by seminal works such as Bennie et al. (2019) and Porter et al. (2019), highlighting the multifaceted nature of physical activity. Our selective emphasis on common exercises like aerobics, weight training, and mixed exercises aligns with prevalent activity guidelines and their noted impact on cardiovascular health. To ensure generalizability and practical relevance, we excluded studies on specialized or uncommon physical activities. The expansion of our literature search to include non-English publications further enhances the scope and diversity of our analysis. This methodological rigor allows our meta-analysis to present a comprehensive overview of impactful physical activities in relation to ischemic heart disease risk, reflecting the exercise habits of the broader population. This study robustly aligns physical activity dimensions—frequency, type, intensity—with US guidelines, demonstrating their cardiovascular benefits. Strict adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) enhances transparency and reproducibility. The use of the Newcastle-Ottawa Scale ensures rigorous quality assessment of the evidence. Employing heterogeneity analysis and random-effects models, the study skillfully manages variability across research, affirming the efficacy of US guidelines in reducing ischemic heart disease risk. This approach underscores the preventive role of exercise in cardiac health. The study’s methodological strength lies in its adaptability, suitable for diverse health, lifestyle, and intervention research. Its versatility extends to various data sources, designs, and populations, promising wider scientific application.

In essence, this research advocates for the inclusion of physical activity guidelines in public health strategies, marking a significant stride in preventive medicine.

This study has some limitations. First, we classified the exercise types but did not account for the baseline and post-exercise development of muscles or body fat. For example, a research article published in 2015 found that quadriceps strength is highly correlated with reduced mortality due to coronary artery disease (Kamiya et al., 2015). Finally, observational studies were selected for this meta-analysis, and most of them were based on self-reports of physical activity; this may negatively affect the statistical power of this study due to the evidence level of studies and recall bias. Moreover, even though the general population was selected, there were unexpected confounders that might have affected the results of the study. Moreover, we emphasize the significance of longitudinal studies, which are key for their statistical power and ability to reveal consistent trends in physical activity and ischemic heart disease (IHD) risk. This approach not only validates our findings but also aligns with advancements in longitudinal research methods. Furthermore, findings may be context-specific and not universally applicable.

Addressing the limitations of cross-sectional data, which provides a snapshot in time, our manuscript highlights the need for longitudinal studies in future research. These studies track changes over time, offering insights into how physical activity patterns evolve and impact IHD risk, thus clarifying causality and temporal relationships. The findings underscore the value of longitudinal research in uncovering causal mechanisms. We advocate for future research to focus on longitudinal designs, involving well-defined cohorts and repeated assessments, to enhance our understanding of the dynamics of physical activity and IHD risk.

Furthermore, in this study, the English-only search strategy enhanced accuracy but also introduced potential bias, limiting the scope of comprehensive research as indicated by Martinez and Hernandez (2021). Recognizing this, multi-language inclusion at the search stage will be beneficial in the future study. Moving beyond the initial Western-centric focus, our review now includes research from Asia, Africa, and South America, offering a global perspective crucial for understanding the diverse factors influencing health outcomes. These methodological enhancements have resulted in a more comprehensive synthesis of global research, aimed at presenting robust findings that contribute to a broader understanding of physical activity’s role in ischemic heart disease. In addition, we critically discuss the potential confounders and challenges associated with self-reported physical activity data, notably recall and misclassification biases. These biases are significant, potentially leading to inaccuracies in reported data on the intensity, duration, and frequency of physical activities, and thereby impacting study outcomes.

Studies such as those by Hu et al. (2007) and Lovasi et al. (2007) illuminate the implications of these biases in physical activity research. In response, our analysis includes a thorough examination of how these biases might have influenced the included studies’ outcomes. This involves assessing the methodologies used, such as validated questionnaires and objective activity monitors, to ensure a more accurate interpretation of results. While our review relies heavily on self-reported data, the incorporation of empirical data obtained through medical instrumentation provides a balance. This approach, including the potential use of objective measures like accelerometers in future research, enhances the credibility of our findings and contributes to the discourse on methodological best practices in physical activity research.

This study provides a critical analysis of the relationship between different types of physical activity and the reduction of myocardial infarction (MI) risk, evaluated within the context of the US physical activity guidelines. Through a comprehensive meta-analysis, it not only identifies the most effective physical activities in reducing MI risk but also highlights the importance of adhering to these guidelines for optimal outcomes. The findings advocate for the integration of regular physical activity into public health policies, essential for mitigating the incidence of ischemic heart disease (IHD). The implications of this study extend beyond academia, suggesting the need for structured community and national programs to improve cardiovascular health. These programs, informed by the study’s insights, could significantly influence health policy and public health initiatives. Future research should concentrate on establishing the effectiveness of physical activity in reducing IHD risk, building on previous studies that suggest regular exercise benefits IHD patients. Emphasizing longitudinal studies and incorporating objective activity measures could refine exercise recommendations, enhancing prevention and management strategies for IHD.

In summary, this study marks a significant advancement in cardiovascular epidemiology, offering insights that can shape future research, health policy, and public health initiatives aimed at combating IHD globally.

Categories of Search Terms (Supplementary file, Data_Sheet_1)

Physical activity [MeSH terms and in title and abstract]: Exercise [MeSH], Physical Conditioning, Human [MeSH], Dancing [MeSH], Swimming [MeSH], Walking [MeSH], Running [MeSH], Bicycling [MeSH], Muscle Stretching Exercises [MeSH], Weight Lifting [MeSH] and related terms (Based on Title and Abstract of the literature).

Ischemic Heart Disease [MeSH terms and in title and abstract]: Myocardial Ischemia [MeSH] (Based on Title and Abstract of the literature).

Incidence [MeSH terms and in title and abstract]: Incidence [MeSH], Heart Disease Risk Factors [MeSH] (Based on Title and Abstract of the literature).

Human Subjects [MeSH terms and in title and abstract]: NOT Models, Animal [MeSH] Disease Models, Animal [MeSH], Animals [MeSH] (Based on Title and Abstract of the literature).

English Only [MeSH terms and in title and abstract]: English [la].

Years [MeSH terms and in title and abstract]: 2000:2022 [dp].

Study Design [MeSH terms and in title and abstract]: NOT Systematic Reviews as Topic [MeSH], Meta-Analysis as Topic [MeSH] (Based on Title and Abstract of the literature).

Supplemental Material

sj-docx-1-sgo-10.1177_21582440241297817 – Supplemental material for Association Between Types of Physical Activity and Risk of Ischemic Heart Disease Based on US Guidelines: A Systematic Review and Meta-Analysis

Supplemental material, sj-docx-1-sgo-10.1177_21582440241297817 for Association Between Types of Physical Activity and Risk of Ischemic Heart Disease Based on US Guidelines: A Systematic Review and Meta-Analysis by Jaewoo Cha, Jeehyun Kim and Kwan Hong in SAGE Open

Footnotes

Acknowledgements

We would like to thank Editage () for editing and reviewing this manuscript for English language.

Author Contributions

Conceptualization: Jaewoo Cha, Methodology: Kwan Hong, Software: Jeehyun Kim, Data curation: Jeehyun Kim, Writing- Original draft preparation: Jaewoo Cha, Visualization: Jaewoo Cha, Investigation: Jaewoo Cha, Supervision: Jaewoo Cha, Validation: Jaewoo Cha, Writing- Reviewing and Editing: Jaewoo Cha

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Jaewoo Cha

Jeehyun Kim

Kwan Hong

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Supplemental Material

Supplemental material for this article is available online.

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