Cardiovascular Mortality, Habitual Exercise, and Particulate Matter 2.5 Exposure: A Longitudinal Cohort Study

Published:October 19, 2022DOI:


      Habitual exercise may amplify the respiratory uptake of air pollutants in the lung, exacerbating the adverse effects of air pollution. However, it is unclear whether this can reduce the health benefits of habitual exercise (referred to as leisure-time exercise). Thus, the combined effects of habitual exercise and chronic exposure to ambient fine particulate matter 2.5 on cardiovascular mortality were examined among adults in Taiwan.


      A total of 384,128 adults were recruited between 2001 and 2016 and followed up to May 31, 2019. Participants’ vital status was obtained by matching their unique identification numbers with records of cardiovascular death in the National Death Registry of Taiwan. A time-varying Cox regression model was used to analyze the data. Analyses were conducted in 2021.


      Cardiovascular death risks were inversely associated with habitual exercise and positively associated with chronic exposure to particulate matter 2.5. The beneficial effects of habitual exercise on cardiovascular mortality were not modified by chronic exposure to particulate matter 2.5. Inactive participants with high particulate matter 2.5 exposure exhibited a 123% higher risk of cardiovascular death than high-exercise-group participants exposed to low levels of particulate matter 2.5 (95% CI=89, 163).


      High level of habitual exercise combined with low exposure level of ambient particulate matter 2.5 is associated with the lowest risk of cardiovascular death. A higher level of habitual exercise is associated with a lower risk of cardiovascular death at all levels of particulate matter 2.5 exposure studied. The results indicate that habitual exercise is a safe health promotion strategy even for people residing in relatively polluted regions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Roth GA
        • Mensah GA
        • Johnson CO
        • et al.
        Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study.
        J Am Coll Cardiol. 2020; 76: 2982-3021
        • Arnett DK
        • Blumenthal RS
        • Albert MA
        • et al.
        2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice guidelines.
        Circulation. 2019; 140: e596-e646
        • Crouse DL
        • Peters PA
        • van Donkelaar A
        • et al.
        Risk of nonaccidental and cardiovascular mortality in relation to long-term exposure to low concentrations of fine particulate matter: a Canadian national-level cohort study.
        Environ Health Perspect. 2012; 120: 708-714
        • Pope 3rd, CA
        • Burnett RT
        • Thurston GD
        • et al.
        Cardiovascular mortality and long-term exposure to particulate air pollution: epidemiological evidence of general pathophysiological pathways of disease.
        Circulation. 2004; 109: 71-77
        • Cao J
        • Yang C
        • Li J
        • et al.
        Association between long-term exposure to outdoor air pollution and mortality in China: a cohort study [published correction appears in J Hazard Mater. 2011;191(1–3):398].
        J Hazard Mater. 2011; 186: 1594-1600
      1. Ostro B, Broadwin R, Green S, Feng WY, Lipsett M. Fine particulate air pollution and mortality in nine California counties: results from CALFINE. Environ Health Perspect. 2006;114(1):29–33.

      2. Andersen ZJ, de Nazelle A, Mendez MA, et al. A study of the combined effects of physical activity and air pollution on mortality in elderly urban residents: the Danish Diet, Cancer, and Health Cohort. Environ Health Perspect. 2015;123(6):557–563.

        • Sun S
        • Cao W
        • Qiu H
        • et al.
        Benefits of physical activity not affected by air pollution: a prospective cohort study.
        Int J Epidemiol. 2020; 49: 142-152
        • Guo C
        • Zhang Z
        • Lau AKH
        • et al.
        Effect of long-term exposure to fine particulate matter on lung function decline and risk of chronic obstructive pulmonary disease in Taiwan: a longitudinal, cohort study.
        Lancet Planet Health. 2018; 2: e114-e125
        • Guo C
        • Zeng Y
        • Chang LY
        • et al.
        Independent and opposing associations of habitual exercise and chronic PM2.5 exposures on hypertension incidence.
        Circulation. 2020; 142: 645-656
        • Guo C
        • Chan TC
        • Teng YC
        • et al.
        Long-term exposure to ambient fine particles and gastrointestinal cancer mortality in Taiwan: a cohort study.
        Environ Int. 2020; 138105640
      3. Ministry of Health and Welfare. Cause of death data. Updated August, 2022. Accessed October 17, 2022.

        • Lao XQ
        • Deng HB
        • Liu X
        • et al.
        Increased leisure-time physical activity associated with lower onset of diabetes in 44 828 adults with impaired fasting glucose: a population-based prospective cohort study.
        Br J Sports Med. 2019; 53: 895-900
        • Guo C
        • Tam T
        • Bo Y
        • Chang LY
        • Lao XQ
        • Thomas GN.
        Habitual physical activity, renal function and chronic kidney disease: a cohort study of nearly 200 000 adults.
        Br J Sports Med. 2020; 54: 1225-1230
        • Guo C
        • Bo Y
        • Chan TC
        • et al.
        Does fine particulate matter (PM2.5) affect the benefits of habitual physical activity on lung function in adults: a longitudinal cohort study.
        BMC Med. 2020; 18: 134
        • Wen CP
        • Cheng TY
        • Tsai MK
        • et al.
        All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan.
        Lancet. 2008; 371: 2173-2182
        • Ainsworth BE
        • Haskell WL
        • Whitt MC
        • et al.
        Compendium of physical activities: an update of activity codes and MET intensities.
        Med Sci Sports Exerc. 2000; 32: S498-S504
        • Samitz G
        • Egger M
        • Zwahlen M.
        Domains of physical activity and all-cause mortality: systematic review and dose-response meta-analysis of cohort studies.
        Int J Epidemiol. 2011; 40: 1382-1400
        • Egan BM.
        Physical activity and hypertension: knowing is not enough; we must apply. Willing is not enough; we must do-von Goethe.
        Hypertension. 2017; 69: 404-406
        • Andersen K
        • Mariosa D
        • Adami HO
        • et al.
        Dose-response relationship of total and leisure time physical activity to risk of heart failure: a prospective cohort study.
        Circ Heart Fail. 2014; 7: 701-708
        • Lin C
        • Li Y
        • Yuan Z
        • Lau AKH
        • Li C
        • Fung JCH.
        Using satellite remote sensing data to estimate the high-resolution distribution of ground-level PM2.5.
        Remote Sens Environ. 2015; 156: 117-128
        • Zhang Z
        • Chang LY
        • Lau AKH
        • et al.
        Satellite-based estimates of long-term exposure to fine particulate matter are associated with C-reactive protein in 30 034 Taiwanese adults.
        Int J Epidemiol. 2017; 46: 1126-1136
        • Chang LY
        • Tsai SP
        • Wang ML
        • et al.
        MJ Health Database (MJHD).
        MJ Health Research Foundation, Beijing, China2016 (Published 2016. Accessed October 17, 2022)
        • Lao XQ
        • Guo C
        • Chang LY
        • et al.
        Long-term exposure to ambient fine particulate matter (PM2.5) and incident type 2 diabetes: a longitudinal cohort study.
        Diabetologia. 2019; 62: 759-769
        • Chiu YF
        • Hsu CC
        • Chiu TH
        • et al.
        Cross-sectional and longitudinal comparisons of metabolic profiles between vegetarian and non-vegetarian subjects: a matched cohort study.
        Br J Nutr. 2015; 114: 1313-1320
        • Zhao M
        • Veeranki SP
        • Li S
        • Steffen LM
        • Xi B.
        Beneficial associations of low and large doses of leisure time physical activity with all-cause, cardiovascular disease and cancer mortality: a national cohort study of 88,140 U.S. adults.
        Br J Sports Med. 2019; 53: 1405-1411
        • Cheng W
        • Zhang Z
        • Cheng W
        • Yang C
        • Diao L
        • Liu W.
        Associations of leisure-time physical activity with cardiovascular mortality: a systematic review and meta-analysis of 44 prospective cohort studies.
        Eur J Prev Cardiol. 2018; 25: 1864-1872
        • DeFina LF
        • Radford NB
        • Barlow CE
        • et al.
        Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification.
        JAMA Cardiol. 2019; 4: 174-181
        • Pedisic Z
        • Shrestha N
        • Kovalchik S
        • et al.
        Is running associated with a lower risk of all-cause, cardiovascular and cancer mortality, and is the more the better? A systematic review and meta-analysis.
        Br J Sports Med. 2020; 54: 898-905
        • Lear SA
        • Hu W
        • Rangarajan S
        • et al.
        The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: the PURE study.
        Lancet. 2017; 390: 2643-2654
        • Dempsey PC
        • Strain T
        • Khaw KT
        • Wareham NJ
        • Brage S
        • Wijndaele K.
        Prospective associations of accelerometer-measured physical activity and sedentary time with incident cardiovascular disease, cancer, and all-cause mortality.
        Circulation. 2020; 141: 1113-1115
        • Thurston GD
        • Ahn J
        • Cromar KR
        • et al.
        Ambient particulate matter air pollution exposure and mortality in the NIH-AARP Diet and health cohort.
        Environ Health Perspect. 2016; 124: 484-490
        • Kim H
        • Byun G
        • Choi Y
        • Kim S
        • Kim SY
        • Lee JT.
        Effects of long-term exposure to air pollution on all-cause mortality and cause-specific mortality in seven major cities of South Korea: Korean national health and nutritional examination surveys with mortality follow-up.
        Environ Res. 2021; 192110290
        • Kim OJ
        • Lee SH
        • Kang SH
        • Kim SY.
        Incident cardiovascular disease and particulate matter air pollution in South Korea using a population-based and nationwide cohort of 0.2 million adults.
        Environ Health. 2020; 19: 113
        • Fisher JE
        • Loft S
        • Ulrik CS
        • et al.
        Physical activity, air pollution, and the risk of asthma and chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2016; 194: 855-865
        • An R
        • Zhang S
        • Ji M
        • Guan C.
        Impact of ambient air pollution on physical activity among adults: a systematic review and meta-analysis.
        Perspect Public Health. 2018; 138: 111-121
        • Zeng Y
        • Lin C
        • Guo C
        • et al.
        Combined effects of chronic PM2.5 exposure and habitual exercise on renal function and chronic kidney disease: a longitudinal cohort study.
        Int J Hyg Environ Health. 2021; 236113791
        • Kubesch NJ
        • Therming Jørgensen J
        • Hoffmann B
        • et al.
        Effects of leisure-time and transport-related physical activities on the risk of incident and recurrent myocardial infarction and interaction with traffic-related air pollution: a cohort study.
        J Am Heart Assoc. 2018; 7e009554
        • Ran J
        • Zhang Y
        • Han L
        • et al.
        The joint association of physical activity and fine particulate matter exposure with incident dementia in elderly Hong Kong residents.
        Environ Int. 2021; 156106645
      4. Elliott EG, Laden F, James P, Rimm EB, Rexrode KM, Hart JE. Interaction between long-term exposure to fine particulate matter and physical activity, and risk of cardiovascular disease and overall mortality in U.S. Women. Environ Health Perspect. 2020;128(12):127012.

        • Kim SR
        • Choi S
        • Kim K
        • et al.
        Association of the combined effects of air pollution and changes in physical activity with cardiovascular disease in young adults.
        Eur Heart J. 2021; 42: 2487-2497
        • Clarkson PM
        • Thompson HS.
        Antioxidants: what role do they play in physical activity and health?.
        Am J Clin Nutr. 2000; 72 (suppl): 637S-646S
        • Rojas-Rueda D
        • de Nazelle A
        • Tainio M
        • Nieuwenhuijsen MJ.
        The health risks and benefits of cycling in urban environments compared with car use: health impact assessment study.
        BMJ. 2011; 343: d4521
      5. Department of Physical Education Ministry of Education. Report of Active Cities, Taiwan. Accessed July 1, 2022.

        • Mazidi M
        • Katsiki N
        • Mikhailidis DP
        • Sattar N
        • Banach M.
        Lower carbohydrate diets and all-cause and cause-specific mortality: a population-based cohort study and pooling of prospective studies.
        Eur Heart J. 2019; 40: 2870-2879