How Has Physical Activity Measurement Evolved Over Time?
Measuring the frequency, intensity, time, domain, and type of adult physical activity has been the cornerstone of physical activity epidemiology since its inception (Sattler et al., 2021). These parameters have shaped how we study the impact of physical activity on health, operationalize relevant guidelines, and conduct population physical activity surveillance. Early measurements of physical activity used subjective (i.e., self-report) questionnaires, such as the Paffenbarger Harvard Alumni Questionnaire, which rely on the respondent’s recall of past or usual participation in physical activities (e.g., sports/recreational activities and stair climbing; Paffenbarger et al., 1978; van Poppel et al., 2010). Because of their low cost and low burden to participants, such questionnaires have been the foundation for empirical studies and surveillance of physical activity and health (Sattler et al., 2021).
While many of the commonly used subjective physical activity assessments regularly collect information about adult physical activity across several domains, most of their application to epidemiologic research and surveillance focuses on leisure-time physical activity. This practice is likely attributable to the relative ease of recall and modifiable nature of leisure-time physical activity, as compared with other domains of physical activity, which can be sporadic, intermittent, and vary in intensity and thus difficult to measure accurately (Physical Activity Guidelines Advisory Committee, 2018; Strath et al., 2013). For example, the National Health Interview Survey, Behavioral Risk Factor Surveillance System, the National Health and Nutrition Examination Survey, Canadian Community Health Survey, European Health Interview Survey, and more are some of the primary sources for physical activity surveillance data around the world and regularly collect information about physical activity across a variety of domains. While these surveillance systems collect information about the multiple physical activity domains, leisure-time physical activity is often the focus of research and reporting utilizing the data.
Although such self-report has provided meaningful physical activity data for many years, biases such as recall, social desirability, and differential reporting across population groups are well-documented limitations to this methodology (Sallis & Saelens, 2000). To address these limitations, device-based estimates of physical activity became popular in the late 1990s and continue widely today in large-scale studies such as the National Health and Nutrition Examination Survey and the U.K. Biobank (Troiano, 2005). Such measurements rely on a device attached to a person’s body, most commonly an accelerometer, that continuously measures movement. Although more complex and costly than methods involving self-report, device-based physical activity assessment methods are not susceptible to many of the biases that limit self-reported measures. As such, device-based physical activity assessment methods are often preferred as research tools and, less commonly, as tools for surveillance.
Importantly, modern device-based physical activity assessment typically captures cumulative daily physical activity and predominantly captures ambulatory movement. This differs inherently from self-reported measures that capture recalled bouts of physical activity within one or more domains. In addition, device-based assessment can measure steps which cannot be practically self-reported.
If physical activity across all domains contributed equally to health, changing to device-based measurement would address the limitations of self-report and enable more precise calculation of the associations between physical activity and health outcomes as well as surveillance estimates. However, standard device-based measures fail to capture potentially important domain information that is more commonly and easily assessed via self-report and may be important for health (Figure 1).
—An overview of physical activity and its measurement across four domains.
Citation: Journal for the Measurement of Physical Behaviour 6, 4; 10.1123/jmpb.2023-0030
Which Physical Activity Domain(s) Are Recommended to Improve Health?
The second edition of the Physical Activity Guidelines for Americans was issued by the U.S. Department of Health and Human Services in 2018, with the overarching message that American adults should “move more and sit less throughout the day” to promote health and reduce the risk of chronic disease (U.S. Department of Health and Human Services, 2018). Similar global recommendations were given by the World Health Organization in 2020 (World Health Organization, 2020). This messaging was developed using data from both self-reported and device-measured physical activity, which related these measures to health outcomes such as all-cause mortality, cardiovascular disease, and cancer (Physical Activity Guidelines Advisory Committee, 2018). Notably, both the U.S. and World Health Organization guidelines use a definition of physical activity that encompasses any bodily movement requiring energy expenditure and therefore purport that the health benefits of physical activity are agnostic to the domain in which the activity is performed (U.S. Department of Health and Human Services, 2018; World Health Organization, 2020). Reflective of this assumption, the U.S. guidelines state, “the purpose of aerobic activity does not affect whether or not it counts toward meeting the key guidelines. For example, physically active occupations can count toward meeting the key guidelines” (U.S. Department of Health and Human Services, 2018). However, due to the nature of measurement previously described, the scientific foundation for these guidelines is based primarily on studies of self-reported leisure-time physical activity and health (Physical Activity Guidelines Advisory Committee, 2018). The health impacts of the other physical activity domains are largely assumed to be similar because, and at the time the guidelines were developed, there were limited data to support or refute this contention. While these widely applicable and domain-agnostic guidelines have considerable public health value in promoting physical activity at the population level, recent research challenges the assumption of equivalent health impacts across all physical activity domains.
Does Physical Activity Domain Modify its Impact on Health?
Copious research over the past 30 years or more supports the assertion that participation in leisure-time physical activity is highly beneficial to health (U.S. Department of Health and Human Services, 2018). By contrast, the evidence is less consistent for other domains (Figure 1). Of particular interest, a growing number of research studies over the past 5 years support a phenomenon known as the “physical activity health paradox.” This research has observed and attempted to explain the paradoxically opposing health effects of leisure-time and occupational physical activity (Holtermann et al., 2018). Starting in 2018, several systematic and umbrella reviews have suggested that occupational physical activity may have a null or even adverse impact on cardiovascular health and all-cause mortality (Cillekens et al., 2020, 2022; Coenen et al., 2018). To a lesser extent, inconsistent associations have also been observed with other nonleisure-time activity. Transportation physical activity such as walking or biking to work has been observed to have mixed impact on all-cause, cardiovascular, or cancer mortality across several studies (Autenrieth et al., 2011; Besson et al., 2008; Dinu et al., 2019; Samitz et al., 2011; Wanner et al., 2014). Household activity or activities of daily living do appear to be protective against all-cause and cardiovascular mortality. However, their health benefits have generally been weaker than those of leisure-time activity (Autenrieth et al., 2011). Moreover, interactions between the health effects of different physical activity domains may also exist and should be considered (Prince et al., 2021). Collectively, these studies support an additional focus on measuring and examining domain-specific physical activity with the goal of clarifying potential effect modification of physical activity–health associations by domain.
How Can We Improve Science, Surveillance, and Health Promotion While Considering Physical Activity Domain?
Surveillance May Be Missing or Not Reporting Nonleisure Domains and Underestimating Total Physical Activity
National surveillance efforts using self-reported data, which have historically focused on leisure-time physical activity, are unable to quantify compliance with the domain-agnostic guidelines (Pate et al., 2018). This discrepancy likely results in a systematic underestimation of the true total physical activity performed, since it fails to capture physical activity within nonleisure domains (Whitfield et al., 2021). Furthermore, this disproportionately underestimates total activity among those who accumulate physical activity primarily through nonleisure domains (i.e., occupation, household, and transportation; Whitfield et al., 2021). We recommend that physical activity surveillance should include measurement of physical activity across all domains to align with current domain-agnostic physical activity recommendations. This could be achieved by utilizing currently collected domain-specific physical activity or by incorporating domain-specific measurement where not already measured (Figure 1).
Domain Matters for Public Health Equity
If domain modifies the health-enhancing effects of physical activity, individuals who accumulate their physical activity primarily through nonleisure domains, such as occupational physical activity, may not be realizing the same health benefits as those accumulating activity primarily during leisure time. Importantly, people with high amounts of nonleisure physical activity are less likely to complete leisure-time activity and more likely to be members of racial, ethnic, or socioeconomic minority groups (e.g., Hispanic/Latinx and non-Hispanic Black; Berrigan et al., 2006; Saint-Maurice et al., 2021) that already experience marked health disparities. We recommend that domain-specific health effects of physical activity should be clarified to inform and promote health equity in future public health guidelines and health promotion efforts (Figure 1).
Research Assessing Physical Activity Should Consider Physical Activity Domain
While device-based measurement of physical activity is considered best practice for free-living assessment, most research focuses on measuring all ambulatory movement throughout the waking period or 24-hr day, without capturing physical activity domains. However, this strategy does not allow for interrogation of the domain-specific impacts of physical activity on health. We recommend that future research should develop and employ practical methods to measure and report domain when measuring physical activity. This could be achieved immediately by further utilizing the domain-specific information often already collected via self-report or potentially improved by employing 24-hr activity recall or ecological momentary assessments within self-report assessments. Device-based assessments could be improved with the addition of activity domain classification via the use of concurrent time-use diaries or other advanced classification techniques such as machine learning (Figure 1).
Physical Activity Interventions Should Consider Domain
Physical activity interventions have focused primarily on increasing physical activity within the domains of leisure time or transportation, showing consistent benefits. Yet the impacts of intervening on occupational and household physical activity are largely unknown. Although many workplace physical activity interventions have been conducted, their primary focus has been on increasing leisure-time physical activity in sedentary workers or reducing sedentary time at work (Dugdill et al., 2008; Malik et al., 2014). These targets have largely ignored potentially impactful interventions seeking to change household or occupational physical activity, which could have high adherence and feasibility because they are linked to productive tasks. Importantly, in the case of occupational physical activity, such interventions may be best initiated at the institutional level as individuals may not have autonomy over their occupational tasks. In addition, interaction effects between domains, such as leisure-time activity interventions in those with high occupational activity, could be beneficial to health and should be explored (Prince et al., 2021). We recommend that physical activity interventions should examine the effectiveness and feasibility of intervening in all physical activity domains (Figure 1).
Conclusions
While the measurement, surveillance, and scope of physical activity research have progressed considerably over the past 30 years, the ongoing focus on leisure-time physical activity still limits our understanding of the connections between physical activity and health. At the same time, the Physical Activity Guidelines for Americans have assumed comparable health benefits of physical activity across all domains. However, sufficient data suggesting potential effect modification between physical activity domains have catalyzed the need to re-evaluate this assumption. To address the most pressing research gaps, it is imperative that the physical activity research community intentionally incorporate the measurement and consideration of all domains into the work of physical activity surveillance, health equity, measurement, and intervention design moving forward.
Acknowledgments
Funding: The project described was supported by the National Institute of General Medical Sciences, 2U54GM104942-07.
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