Highlights
– Objective accelerometer data in 13,547 older women show that meeting a modest threshold (≥4,000 steps/day) on even 1–2 days/week is associated with lower all‑cause mortality and lower incidence of cardiovascular disease (CVD).
– Increasing the daily step threshold (5000–7000) was linked to progressively lower mortality in a curvilinear fashion, but associations were attenuated after adjusting for mean daily steps, indicating total step volume largely mediates benefit.
– Clinical implication: among older women, any increase in step accumulation—regardless of weekly pattern—appears beneficial; clinicians can endorse achievable, volume-focused step goals.
Background
Walking is the most commonly performed form of physical activity in older adults and is a practical target for behavior change. Public health recommendations emphasize accumulating moderate-to-vigorous physical activity across the week, but many older adults struggle to meet time‑based guidelines. Step counts measured by accelerometers provide a simple, objective metric of ambulatory activity and are increasingly used in epidemiological research and clinical practice. Understanding whether the pattern of meeting step thresholds across the week matters — for example, a few active days versus being active most days — is important for real-world counseling and for designing behavior-change interventions tailored to older women.
Study design
This prospective cohort analysis by Hamaya et al. (Br J Sports Med, 2025) evaluated 13,547 women (mean age 71.8 years) free of cardiovascular disease and cancer at baseline. Participants wore an ActiGraph GT3X+ accelerometer for seven consecutive days during 2011–2015. Researchers classified each woman by the number of days per week achieving daily step thresholds of ≥4,000, ≥5,000, ≥6,000, or ≥7,000 steps/day and followed them for mortality through 2024 and for incident CVD.
Primary outcomes were all‑cause mortality and new cardiovascular events. Cox proportional hazards models estimated hazard ratios (HR) and 95% confidence intervals (CI) for risk across categories of days-per-week meeting each threshold, adjusting for demographics, lifestyle behaviors, body mass index, and comorbidities. Additional models adjusted for mean daily steps to evaluate whether the frequency effect was independent of overall step volume.
Key findings
Over a median follow-up of 10.9 years, 1,765 women (13.0%) died and 781 (5.1%) developed incident CVD. The principal and most clinically actionable findings are summarized below.
1. Low threshold activity on few days confers benefit
Compared with women who did not achieve ≥4,000 steps on any monitored day, women who achieved ≥4,000 steps on 1–2 days/week had a 26% lower adjusted risk of all‑cause mortality (HR 0.74; 95% CI 0.65–0.86). Those who reached ≥4,000 steps on ≥3 days/week had a 40% lower mortality risk (HR 0.60; 95% CI 0.53–0.68).
For incident CVD, achieving ≥4,000 steps on 1–2 days/week was associated with a 27% lower risk (HR 0.73; 95% CI 0.58–0.92), and achieving the threshold on ≥3 days/week also had a similar 27% lower risk (HR 0.73; 95% CI 0.60–0.89).
2. Higher daily step thresholds yielded progressively lower mortality
When investigators examined higher daily thresholds (5,000; 6,000; 7,000 steps/day), an inverse curvilinear dose–response relationship with mortality was observed: mortality risk declined further with higher thresholds, although the incremental benefit beyond the 4,000-step mark was modest. Exact HRs for higher thresholds were reported in the manuscript and indicate consistent directionality favoring more steps.
3. Total step volume is the key mediator
Importantly, when models included mean daily steps as an additional covariate, the associations between the number of days meeting thresholds and both mortality and CVD were attenuated to the null. This suggests that the frequency pattern per se (i.e., the number of days achieving a step count threshold) is less important than the overall accumulated steps over time: total step volume largely explains the observed associations.
4. Robustness and subgroups
The study adjusted for a broad range of confounders, including smoking, alcohol use, medication use, and prevalent comorbid conditions. Sensitivity analyses reported in the paper (for example, excluding early deaths to mitigate reverse causation) supported the primary findings, although residual confounding and measurement limitations remain possible.
Expert commentary and interpretation
Clinical translation: The results are reassuring from a public‑health and clinical counseling perspective. For older women, the message that ‘some steps are better than none’ is validated by objective accelerometer data and prolonged follow-up. A target such as achieving ≥4,000 steps on one or two days per week—which may reflect relatively modest activity for many—is associated with lower mortality and CVD risk. However, the attenuation after adjustment for mean daily steps clarifies an important nuance: clinicians should emphasize cumulative activity (total steps per day or week) rather than focusing narrowly on whether a threshold was reached on a given day.
Biological plausibility: Walking improves multiple risk factors for cardiovascular disease, including blood pressure, glycemic control, endothelial function, and body composition. Regular ambulatory activity may also reduce systemic inflammation and enhance cardiorespiratory reserve, thereby lowering mortality and CVD risk. The curvilinear pattern—largest gains at lower volumes with diminishing marginal returns—aligns with prior physical activity literature showing substantial benefit from moving from sedentary to moderately active levels.
Strengths: Key strengths include the large cohort of older women, objective accelerometer-assessed step counts, and long median follow-up with adjudicated outcomes. The paper addresses a clinically relevant question about the pattern of activity across the week rather than only average volume.
Limitations and caveats:
- Single baseline week of accelerometer measurement may not capture long-term behavioral patterns; step counts can vary seasonally and year-to-year.
- Residual confounding remains possible in observational research despite extensive covariate adjustment. Poor health at baseline could limit activity and increase short-term mortality (reverse causation), though sensitivity analyses mitigate this concern.
- Generalizability: cohort composed of older women; results may not directly apply to men or younger populations, or to populations with different sociodemographic characteristics.
- Device limitations: wrist/hip accelerometers estimate steps but may misclassify some non-ambulatory movements; algorithm differences across devices can affect counts.
Clinical and public health implications
For clinicians counseling older women, practical takeaways include:
- Encourage any increase in step accumulation; even modest, intermittent gains matter. Messaging that ‘some steps on some days count’ may be more achievable and motivating for sedentary older adults than an all‑or‑nothing daily target.
- Prioritize total step volume over rigid patterns. If a patient prefers longer walks on fewer days (for example, weekend walking), this pattern still contributes to cardiovascular risk reduction if total weekly steps rise.
- Use wearable devices pragmatically. Simple step goals and feedback can foster behavior change; clinicians should individualize targets based on comorbidity, mobility, and fall risk.
- Combine step promotion with other risk‑factor management (blood pressure, lipids, smoking cessation) for additive cardiovascular benefit.
Research implications and future directions
Key areas for further work include:
- Longitudinal measurement: Repeat accelerometer assessment over time would clarify the impact of sustained versus transient changes in step volume.
- Intervention trials: Randomized trials that test step‑based prescriptions (e.g., progressive weekly volume targets vs. daily fixed goals) would establish causality and inform optimal behavioral prescriptions for older adults.
- Population diversity: Additional studies in men and in diverse racial/ethnic and socioeconomic groups are needed to test external validity and equity of recommendations.
- Integration with clinical workflows: Implementation research can evaluate how best to incorporate step tracking into routine geriatric and cardiovascular preventive care.
Conclusion
In this large cohort of older women with objective step measurement and long follow-up, achieving ≥4,000 steps on even 1–2 days per week was associated with meaningful reductions in all‑cause mortality and cardiovascular events. Increasing daily step thresholds conferred additional benefit in a curvilinear manner. Crucially, the observed associations were largely explained by mean daily steps, emphasizing that total step volume—rather than the weekly pattern of meeting specific daily thresholds—is the dominant factor associated with better outcomes. Clinicians should therefore encourage achievable increases in cumulative ambulatory activity and tailor goals to individual capacity and preferences.
Funding and registration
Funding and detailed trial/registry information are reported in the original publication: Hamaya R, Evenson KR, Lieberman D, Lee IM. Association between frequency of meeting daily step thresholds and all-cause mortality and cardiovascular disease in older women. Br J Sports Med. 2025. For observational cohort analyses, ClinicalTrials.gov registration is not typically applicable; readers should consult the manuscript for specific funding disclosures and data‑sharing statements.
References
1. Hamaya R, Evenson KR, Lieberman D, Lee IM. Association between frequency of meeting daily step thresholds and all-cause mortality and cardiovascular disease in older women. Br J Sports Med. 2025 Oct 21. doi:10.1136/bjsports-2025-110311.
2. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. 2018. Available at https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf.
3. World Health Organization. WHO guidelines on physical activity and sedentary behaviour. 2020. Available at https://www.who.int/publications/i/item/9789240015128.
