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Global health
Original research
Objectively measured daily steps and health outcomes: an umbrella review of the systematic review and meta-analysis of observational studies
  1. Chunlan Xu1,
  2. Jinli Jia1,
  3. Binbin Zhao1,
  4. Man Yuan1,
  5. Nan Luo1,
  6. Fan Zhang2,
  7. Hui Wang1
  1. 1Department of Nursing, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
  2. 2Department of Nephrology A, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
  1. Correspondence to Dr Fan Zhang; 1051071914{at}qq.com; Mrs Hui Wang; gcd159{at}163.com

Abstract

Objectives The purpose of this review is to summarise the evidence from a systematic review and meta-analysis of observational studies that objectively measure daily steps and health outcomes.

Design This is an umbrella review.

Data sources PubMed, Embase, Scopus, the Cochrane Library and Web of Science databases were searched through 31 January 2024.

Eligibility We included systematic reviews of observational studies (with or without meta-analysis) that assessed the association of objectively measured daily steps with human health-related outcomes. Methodological quality was assessed using ‘A MeaSurement Tool to Assess systematic Reviews 2’.

Results A total of 10 systematic reviews and 6 health outcomes were included after excluding irrelevant and duplicate studies. Higher daily steps were associated with more benefits than harms for a range of health-related outcomes, including all-cause mortality, cardiovascular event, skeletal muscle lesions, metabolic diseases and respiratory disease. A dose-response analysis showed that an increase of 500–1000 steps per day was associated with lower all-cause mortality and cardiovascular events. Beneficial associations were also found in patients with asthma and acutely hospitalised older adults. Conversely, one study within a systematic review suggested that higher daily steps (≥10 000) might be associated with an increased 52% risk of meniscal pathologies in individuals without knee osteoarthritis. However, one study within a systematic review suggested a potential increased risk of meniscal pathologies in individuals without knee osteoarthritis. Specifically, those exceeding 10 000 steps per day showed a 52% increase in risk.

Conclusion The results of this study suggest that daily steps are associated with a lower risk of all-cause mortality and cardiovascular events. Future research could focus on identifying specific populations that may benefit most from increased daily steps and exploring potential mechanisms to enhance our understanding of how daily steps contribute to improved health outcomes.

PROSPERO registration number CRD42022347055.

  • Health
  • Systematic Review
  • Meta-Analysis
  • Physical Examination

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2024-088524

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This review conducted a comprehensive search of multiple databases to identify studies of steps-based physical activity and prognosis.

    • Different characteristics of the included population may give rise to heterogeneity.

    • Language limitation may have resulted in missing studies that should have met the eligibility criteria.

    Introduction

    Physical activity is any physical movement produced by skeletal muscle that requires energy expenditure.1 Physical inactivity is a global public health concern; it was reported that more than 31% of adults globally do not meet the WHO recommended physical activity levels, which is linked to a higher risk of mortality among older adults and individuals with non-communicable diseases such as cardiovascular disease, chronic kidney disease and diabetes mellitus.2–7 For example, Paudel et al demonstrated that individuals engaging in lower physical activity had a 62% higher risk of all-cause mortality.5 Daily steps are a simple, objective measure of physical activity that can be easily understood and used by most individuals.8 With the increasing popularity of wearable devices (eg, accelerometers and pedometers), monitoring daily steps are more feasible than ever for the public.9

    In recent years, the literature investigating the association between daily steps and health outcomes in healthy populations and patients with chronic diseases has grown exponentially.10–15 Del Pozo Cruz et al11 showed that the optimal dose (ie, exposure value at which the maximum risk reduction was observed) for daily steps and dementia was 9826 steps (HR: 0.49; 95% CI 0.39 to 0.62) and the minimal dose (ie, exposure value at which the risk reduction was 50% of the observed maximum risk reduction) was 3826 steps (HR: 0.75; 95% CI 0.67 to 0.83). With this, systematic reviews with meta-analysis are also on the rise. However, to date, most systematic reviews have focused on a single disease endpoint and have not systematically assessed the relationship between daily steps and different physical and mental health outcomes. A systematic review by Paluch et al16 specifically examined the impact of daily steps on cardiovascular disease, highlighting that monitored and promoted steps per day are a simple metric for clinician–patient communication and population health to reduce the risk of cardiovascular disease.

    Despite the known benefits, the literature on daily steps and health outcomes is fragmented, with many studies focusing on specific disease endpoints. This fragmentation makes it challenging to gain a comprehensive understanding of the overall impact of daily steps on health.

    Umbrella reviews synthesise evidence from multiple systematic reviews and meta-analyses, providing a broad overview of a research topic. Unlike traditional systematic reviews that focus on specific questions, umbrella reviews integrate findings to reveal overarching patterns and insights.17 They address the limitations of individual reviews by offering a higher-level perspective, highlighting inconsistencies and identifying gaps in the literature.

    Recently published two umbrella reviews on step counts and health outcomes did not account for overlapping meta-analyses,18 19 focus on a single outcome or exclude intervention studies, which may introduce bias related to the relationship between interventions and step count increases. With this in mind, this review aims to systematically identify systematic reviews of observational studies (including cross-sectional or cohort studies) of daily steps and summarise their results to provide a comprehensive understanding of the association between daily steps and health outcomes in humans.

    Methods

    The protocol of this study is registered with PROSPERO (registration number: CRD42022347055). This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 reporting guidelines20 (online supplemental table S1).

    Patient and public involvement

    In this study, direct patient and public involvement was not included. The primary reason for this decision was the nature of the research, which focused on synthesising existing literature through an umbrella review rather than conducting new primary research or clinical trials. Umbrella reviews aim to aggregate findings from published systematic reviews and meta-analyses, which primarily involve secondary data analysis. Additionally, the scope of this study was to provide a comprehensive overview of existing evidence on a broad topic, which did not necessitate the collection of new data or insights from patient populations. However, we acknowledge the importance of patient and public perspectives and suggest that future research could benefit from their involvement, particularly in interpreting findings and shaping practical recommendations.

    Data sources and search strategy

    We searched PubMed, Embase, the Cochrane Library, Scopus and Web of Science databases from inception to 31 July 2022 and updated in September 2024 to identify systematic reviews of observational studies. The search strategy was designed to capture a wide range of studies related to daily steps and health outcomes. Key search terms included combinations of “daily steps,” and “systematic review.” Boolean operators such as “AND” and “OR” were used to refine the search results and ensure the inclusion of relevant literature. The detailed search strategies for all databases were presented in online supplemental table S2. The search was updated on 1 March 2023 for the most recently published literature that might meet the eligibility criteria. In addition, we manually reviewed the reference lists of similar reviews.21 22 The language was restricted to articles published in English.

    Identified studies were imported into EndNote 20, and duplicates were removed. Two authors independently screened titles and abstracts for relevance and selected studies after checking the full text of potentially eligible studies. Any disagreements were resolved through discussion with a third reviewer.

    Eligibility and exclusion criteria

    In this umbrella review, we included systematic reviews and/or meta-analyses of observational studies that investigated the relationship between daily steps and any health outcome. Articles meeting the following criteria were included: (1) systematic reviews (with or without meta-analysis) of observational studies assessing daily steps concerning health outcomes in both adults and children, with or without any disease; (2) studies using self-reported (eg, depression scale), observational (eg, clinical diagnosis) or objective (eg, mortality) criteria as an outcome; and (3) in cases where multiple systematic reviews and meta-analyses addressed the same health outcome, we initially selected the review with the most studies included to ensure comprehensiveness. We excluded letters, conference abstracts, narrative reviews and other studies designed for systematic reviews and meta-analyses.

    Study selection

    Two independent authors screened the title and abstract of each citation based on eligibility criteria. The reviewers’ decisions to include or exclude all retrieved studies were recorded in the EndNote 20 software. Potentially eligible studies were highlighted and retrieved for full-text evaluation, and the reasons for excluding ineligible studies were recorded. We resolved any disagreements through discussion and consulted a third author if needed.

    Data extraction

    Two independent authors extracted the following data from the included systematic reviews and meta-analyses: first author, publication year, study population, number of included studies and the total number of included studies, follow-up time, step threshold with corresponding maximum adjusted estimated effect and health outcomes. If there were two systematic reviews covering the same association, we included the one with the highest number of studies.

    After initial extraction, the data from both reviewers were compared. Any discrepancies identified were discussed in a consensus meeting. If discrepancies persisted, a third reviewer was consulted to make a final decision, ensuring that the extracted data accurately reflected the original studies. Regular meetings were held to discuss any challenges encountered during data extraction and to ensure adherence to the protocol.

    Quality assessment

    Two authors independently evaluated the methodological quality of the included systematic reviews using the ‘A MeaSurement Tool to Assess systematic Reviews 2’ (AMSTAR-2).23 This checklist contains 16 items and each item was answered with ‘yes’, ‘no’, ‘can not answer’ or ‘not applicable’. Based on these answers, only the ‘yes’ answer was counted as a point in the total score for the assessed study. Thus, the meta-analyses were categorised as high quality (at least 80% of the items were satisfied), moderate quality (between 40% and 80% of the items were satisfied) or low quality (<40% of the items were satisfied).24

    Results

    Study selection

    The literature search identified 833 records; after eliminating duplicate studies, 52 full-text articles were reviewed and finally, 13 studies were included in the systematic review16 25–33 (see online supplemental table S3 for reasons for excluded full-text articles), of which four29 31 34 35 and two35 36 systematic reviews reported associations between daily steps and all-cause mortality and cardiovascular disease, respectively, and after discussion, we excluded studies by Jayedi et al,29 Liu31 and Sheng et al.35 Therefore, 10 systematic reviews were ultimately included in this umbrella review (figure 1).

    Figure 1
    Figure 1

    Study selection flow chart.

    Characteristic of included systematic review

    The 10 studies included in this umbrella review were published between 2018 and 2023 (table 1). These systematic reviews analyse 127 primary studies (ranging from 1 to 36 per review) involving 128 766 participants (ranging from 313 to 47 471 per review). Daily steps were considered as an exposure variable, while health outcomes assessed included cardiovascular disease event/biomarkers, asthma prognosis, intra-articular knee joint structures, adiposity, cardio-metabolic risk factors, all-cause mortality, arterial stiffness, hospital-related event and dysglycaemia (table 1). Notably, two studies focused on children and adolescents,27 33 while the sample of the other studies consisted of adult populations.

    View this table:
    Table 1

    The characteristic of included review

    Methodological quality assessment

    The methodological quality of the five included meta-analyses is summarised in online supplemental table S4. Two, three and five studies were classified as being of moderate methodological quality, respectively. None of the reviews met the AMSTAR-2 items 10 criteria, referring to the explanation for sources of funding for the included studies. Moreover, all studies met items 1 and 8 of the criteria which are related to clear research questions and inclusion criteria and description of the included studies (online supplemental table S4).

    Finding

    Daily steps and all-cause mortality

    A systematic review and dose-response meta-analysis by Paluch et al34 that included 15 studies showed a 40% lower all-cause mortality risk in the lower daily steps group (HR: 0.60, 95% CI 0.51 to 0.71), a 45% lower all-cause mortality risk in the higher daily steps group (HR: 0.55, 95% CI 0.49 to 0.62) and 53% lower all-cause mortality risk in the highest daily steps group (HR: 0.47, 95% CI 0.39 to 0.57). Further analysis found that the mortality risk gradually decreased with increasing daily steps and did not decrease further when a certain number of daily steps were reached. For adults aged 60 years and younger, the mortality risk was lowest for walking 8000–10 000 steps per day, and for older adults aged 60 years and older, the mortality risk was lowest for walking 6000–8000 steps per day.

    Daily steps and cardiovascular event

    A meta-analysis of eight studies pooled by Paluch et al16 reported that for older adults, compared with the lowest quartile, quartile 2 had a 20% lower risk of cardiovascular disease (HR: 0.80; 95% CI 0.69 to 0.93), quartile 3 had a 38% lower risk (HR: 0.62; 95% CI 0.52 to 0.74), and quartile 4 had a risk was reduced by 49% (HR: 0.51; 95% CI 0.41 to 0.63). For younger adults, the HRs suggest a trend towards lower risk of cardiovascular disease in the higher quartiles compared with the lowest quartile, with HRs of 0.79 (second quartile), 0.90 (third quartile) and 0.95 (fourth quartile). Although the confidence intervals (95% CI for second quartile, 0.46 to 1.35; third quartile, 0.64 to 1.25; fourth quartile, 0.61 to 1.48) include 1.0, indicating a lack of statistical significance, the observed HRs may still provide useful insights into potential trends.

    A meta-analysis by Cavero-Redondo et al,25 which included 10 cross-sectional studies in adults and older adults, reported that daily steps were inversely associated with arterial stiffness as measured by pulse wave velocity (r=−0.18; 95% CI −0.27 to −0.10). The regression models indicated that higher levels of daily steps were associated with lower pooled pulse wave velocity values (P for trend=0.005).

    A systematic review by Gordia et al27 reported the association between daily steps and cardiometabolic risk factors in children and adolescents. However, included studies showed a lack of association between daily steps and hyperglycaemia, were inconclusive regarding lipid changes, diverged from hypertension, and showed an association with insulin resistance and metabolic syndrome only in men.

    Daily steps and skeletal muscle lesions

    Xu et al37 focused on the relationship between physical activity and MRI features of knee osteoarthritis in individuals without knee osteoarthritis. While only 1 out of 11 studies reported a potential association between walking more than 10 000 steps per day and higher meniscal lesion scores (OR: 1.52; 95% CI 1.05 to 2.20), 4 studies found a protective association with physical activity, though this may not have been specifically measured by steps per day.

    Daily steps and metabolic diseases

    A pooled analysis of cross-sectional studies by Lu et al32 reported no significant correlation between daily steps and fasting glucose (r=−0.12; 95% CI −0.24 to 0.01) and high-density lipoprotein (r=0.24; 95% CI −0.07 to 0.54).

    In the adolescent population, a systematic review by Miguel-Berges et al33 found consistent evidence of a negative association between daily steps and adiposity; a significant negative association was observed in 72% (26/36) of the studies.

    The study by Hall et al28 reviewed the association between daily steps and abnormal blood glucose, but the results of the studies were mixed.

    Daily steps and respiratory disease

    Cordova-Rivera et al26 evaluated the associations between physical activity and the clinical and physiological characteristics of asthma. Among the 7 studies reviewed, only 1 reported a specific association: an increase of 1000 daily steps was linked to a 17% reduction in systemic inflammation, as measured by hypersensitivity C-reactive protein levels.

    Other

    Levin et al30 systematically reviewed the relationship between step counts and hospitalisation-related outcomes in acutely hospitalised older adults and reported that lower daily steps during hospitalisation were associated with functional decline, longer hospital stays and higher rehospitalisation rates.

    Discussion

    In total, we identified 10 systematic reviews of daily steps and health outcomes in this umbrella review. Based on the available evidence, higher daily steps are more beneficial than harmful for a range of health-related outcomes. Beneficial associations were found for all-cause mortality risk, cardiovascular disease, metabolic disease, respiratory disease and acute hospitalised elderly prognosis. However, it is important to note that the association between a daily step count of ≥10 000 and a higher risk of meniscal lesions in individuals without knee osteoarthritis was reported in only one study. Nonetheless, while increasing daily steps can generally contribute to better health outcomes, it is important to recognise that the optimal number of steps may vary among individuals. Therefore, healthy people and those with chronic diseases should aim to gradually increase their daily steps, taking into account their personal health conditions and capabilities.

    In this overall review, higher daily steps are associated with lower all-cause mortality. The popularity of wearable devices has made daily steps a common method for assessing physical activity. Numerous studies indicate a positive link between higher levels of physical activity and reduced mortality risk.38–44 The umbrella review by Rodríguez-Gutiérrez et al19 highlights a significant inverse relationship between daily steps and mortality risk across diverse populations. Findings show that each additional 1000 daily steps is linked to a 23% reduction in mortality risk.35 Moreover, walking 8000–10 000 steps daily is associated with the lowest mortality risk for adults aged 18–60, while older adults benefit from walking 6000–8000 steps per day.34 Notably, the study by Saint-Maurice et al45 found no significant association between walking intensity and mortality, suggesting that even a simple daily walk can reduce all-cause mortality risk.

    As with all-cause mortality, there was also a significant negative association between daily steps and cardiovascular events. A meta-analysis by Sheng et al35 showed that each 500-step increase in daily steps was associated with a 6% reduction in the risk of cardiovascular disease (RR: 0.94; 95% CI 0.91 to 0.97). In a recently published meta-analysis, higher daily steps were found to be associated with a reduced risk of cardiovascular disease in older adults (≥60 years), with 6000 to 9000 steps per day being associated with a 40% to 50% reduction in cardiovascular disease risk compared with 2000 steps per day.16 However, the study did not find a correlation in younger adults, possibly for the following reasons: cardiovascular disease is common in older adults, and the follow-up period of the study may not be long enough to record cardiovascular events in younger adults. In a slight departure from all-cause mortality, a large cohort study of 78 500 people aged 40–79 years illustrated that more daily steps, more purposeful walking and higher walking intensity (step frequency) were associated with a lower risk of cardiovascular disease.36

    This review also identified a positive association between higher daily step counts and improved outcomes in asthma management and reduced acute hospitalisation rates among older adults. However, it also noted a potential association with an increased risk of lesions in individuals without knee osteoarthritis. These results indirectly suggest a dose-response relationship between daily steps and health-related outcomes, that is, 10 000 daily steps may not be appropriate for all populations. The number of daily steps required varies among individuals due to many differences in age, physical fitness and living conditions. The study by Lee et al46 showed that 4400 steps/day was significantly associated with lower mortality compared with 2700 steps/day. Increasing this number provides additional benefits but balances out at approximately 7500 steps/day. If an individual aims to lose weight or reduce the risk of metabolic syndrome, an increase in daily steps needs to be considered. In one study, it was found that individuals who achieved approximately 15 000 steps per day had a lower risk of metabolic syndrome and were more conducive to weight loss.47 On the other hand, while there is no scientific evidence suggesting that more than 10000 steps per day is excessive for older adults or those with chronic diseases, a lower step goal may be more appropriate. This is due to the typically low baseline activity levels in older adults and the beneficial associations observed at lower step volumes below 10 000 steps per day.

    In our review, we identified that the relationship between daily steps and health outcomes, such as all-cause mortality,34 may not be strictly linear. Some studies suggest that initial increases in daily steps can lead to significant health benefits, but these benefits may plateau at higher levels of physical activity, indicating a potential non-linear relationship. However, due to limited data, further research is needed to clarify these dose-response dynamics. Understanding these patterns is vital for developing precise public health recommendations regarding physical activity.

    Clinical implications

    Based on our synthesis of the current evidence, we propose specific recommendations regarding daily step counts to improve various health outcomes. Our analysis suggests the following:

    • All-cause mortality: adults aged 60 years and older with increasing daily steps per day until 6000–8000 steps per day and among adults younger than 60 years until 8000–10 000 steps per day.

    • Cardiovascular health: among older adults, taking 6000 to 9000 steps per day was associated with 40% to 50% lower risk of cardiovascular disease. Considering the insufficient nature of evidence for other outcomes, future studies need to further explore the benefit of daily steps.

    In terms of increasing daily steps, the Verywellfit website48 has listed a series of measures that contribute to breaking long periods of sedentary behaviour:

    1. Drinking lots of water (you will have to get up often to refill your bottle and use the restroom).

    2. Going for a walk during your lunch break.

    3. Scheduling walking meetings.

    4. Setting an alarm on your phone to get up every hour on the hour.

    5. Standing and pacing while you talk on the phone.

    6. Taking a periodic ‘walk break’.

    7. Taking the stairs whenever possible.

    8. Using the furthest parking spot.

    Future direction

    Our review found limited evidence on the association between daily steps and fitness and mental health outcomes, highlighting a significant gap in the literature. Physical activity, including walking, is often linked to improvements in physical fitness and mental well-being. Future research should explore how different step counts and walking intensities affect fitness parameters such as cardiovascular endurance, muscular strength and flexibility. Additionally, examining the impact of daily steps on mental health outcomes like stress reduction, mood enhancement and cognitive function could provide valuable insights and inform public health recommendations.

    Limitation

    The umbrella review has several unavoidable limitations. First, daily steps are only one indicator of physical activity. While we aimed to include all relevant studies, some studies may not have explicitly mentioned daily steps in their titles or abstracts, which could complicate their identification. However, we believe that our search strategy was comprehensive, and we will review it to ensure all relevant articles were captured. Second, we did not grade the evidence for the meta-analysis, which may limit the generalisability of the results due to inadequate raw data reporting in most studies. Third, our review only included literature published in English, which may have resulted in missing studies that could meet the eligibility criteria and may introduce language bias. Fourth, our inclusion criteria focused on observational studies, which may have led to the exclusion of relevant intervention studies that could provide additional insights into the benefits of increasing daily steps. Fifth, the included studies varied in population characteristics, study design and outcome measures, leading to heterogeneity that complicates result synthesis and may affect overall conclusions. Lastly, the quality of the included reviews varied, and lower-quality studies may introduce biases that affect the robustness of our conclusions.

    Conclusion

    Daily steps are associated with several human health-related outcomes, including all-cause mortality and cardiovascular disease event. In terms of patient care, daily steps are a targetable and changeable risk factor that can be used to identify early health prognosis and guide healthcare in healthy populations and patients with chronic diseases. Observational studies included in this review suggest that increasing daily step counts is associated with various health benefits across diverse populations. While these findings highlight the potential of daily step counts as a marker for physical activity, further research is needed to explore the effectiveness of specific interventions.

    Data availability statement

    Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Footnotes

    • Contributors Conceptualisation: FZ and CX. Data curation: JJ, MY, NL and BZ. Formal analysis: FZ and CX. Methodology: FZ and CX. Project administration: HW and FZ. Software: FZ. Supervision: HW and FZ. Writing-original draft preparation: FZ and CX. Writing-review and editing: FZ and HW. FZ is the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, conduct, report or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.