Abstract
Patients with chronic kidney disease (CKD) are at an increased risk of mortality. Whether adherence to the Canadian 24-Hour Movement Guidelines, which integrate moderate-to-vigorous physical activity (MVPA), sedentary behavior (SB), and sleep time (ST), is associated with improved survival in this population remains unclear. We analyzed 5578 adults with CKD from the National Health and Nutrition Examination Survey (NHANES) 1999–2018 linked to National Death Index mortality data through 2019. Adherence to guideline components was assessed using self-reported measures. Multivariable Cox proportional hazards models were used to estimate the adjusted hazard ratio (HR) and 95% confidence interval (CI) for all-cause mortality. Meeting the MVPA or SB recommendations individually was associated with lower all-cause mortality (MVPA: HR = 0.48; SB: HR = 0.75), whereas meeting the sleep recommendation alone was not significantly associated with mortality. Greater benefits were observed for combined adherence to guideline components (MVPA + SB: HR = 0.47; MVPA + ST: HR = 0.42; SB + ST: HR = 0.67; all 3 components: HR = 0.45). Sex-stratified analyses demonstrated significant survival benefits in both men and women. Age-stratified analyses showed a more pronounced survival advantage among participants aged ≥65 years, whereas associations were weaker and generally not statistically significant among those aged <65 years. Among adults with CKD, adherence to the Canadian 24-Hour Movement Guidelines was associated with lower all-cause mortality, particularly among older adults (≥65 years). Promoting a combination of adequate physical activity, reduced sedentary behavior, and healthy sleep may have important implications for improving survival in this high-risk population.
Keywords: 24-hour movement guidelines, age disparities, chronic kidney disease, mortality, NHANES
1. Introduction
Chronic kidney disease (CKD) has become an increasingly serious public health challenge. According to 2024 estimates, approximately 700 million people worldwide are affected by CKD, increasing to about 850 million when end-stage renal disease is included – representing more than 10% of the global population.[1] Notably, CKD has a significant impact on mortality: it is currently the third fastest-growing cause of death worldwide and is projected to rank among the top 5 causes of years of life lost by 2040.[1-3] This burden is also evident in high-income countries; for instance, more than 1 in 7 adults in the United States (approximately 35.5 million people, or 14%) are affected by CKD.[4] These data indicate that CKD affects a large and growing proportion of adults, with substantial implications for both national and global health.
Among chronic diseases, modifiable lifestyle behaviors – particularly physical activity, sedentary time, and sleep – have a substantial impact on health outcomes. Physical inactivity is a significant risk factor for premature mortality, accounting for approximately 9% of all deaths worldwide.[5] Excessive sedentary behavior independently increases the risk of cardiovascular disease and all-cause mortality. This pattern is particularly pronounced among CKD patients. For example, adults with impaired kidney function who sit for more than 6 h/d have significantly higher all-cause mortality compared with more active individuals.[6] Similarly, sleep duration is critical for longevity. Extensive cohort studies have demonstrated a U-shaped association between nightly sleep duration and mortality, with both short sleep (<7 hours) and long sleep (>8 hours) being associated with increased all-cause mortality.[7] In summary, maintaining adequate physical activity, minimizing prolonged sedentary behavior, and sustaining healthy sleep patterns are key strategies for reducing the risk of chronic disease and mortality.[8-10]
In light of these interconnected effects, recent public health guidelines have adopted a comprehensive 24-hour movement approach. The Canadian 24-Hour Movement Guidelines exemplify this approach, providing an integrated framework that combines daily activity targets, limits on sedentary behavior, and sleep recommendations.[11] These guidelines emphasize that “all movement matters,” highlighting the importance of balancing different activities across the 24-hour day. Importantly, evidence suggests that adults who meet combined targets for physical activity, sedentary time, and sleep have significantly lower risks of all-cause mortality and cardiovascular disease compared with those who do not meet these recommendations.
Although this prospect is encouraging, it remains uncertain whether these 24-hour movement guidelines are equally applicable to vulnerable populations such as CKD patients. CKD patients are generally less active and more sedentary than the general adult population[12]; however, evidence regarding comprehensive lifestyle recommendations tailored to patients with CKD remains limited. Indeed, current exercise recommendations for CKD – such as 150 minutes of moderate-intensity activity per week – are primarily extrapolated from guidelines for the general population due to the limited number of CKD-specific trials. To our knowledge, no studies have evaluated whether adherence to comprehensive guidelines for physical activity, sedentary behavior, and sleep confers survival benefits in patients with CKD. This gap is critical: demonstrating that adherence to healthy 24-hour movement patterns reduces mortality in CKD patients would provide essential evidence to inform lifestyle recommendations and public health strategies for this high-risk population.
Therefore, this study aimed to investigate the association between adherence to Canadian 24-Hour Movement Guidelines and all-cause mortality among adults with CKD. Using nationally representative cohort data with long-term mortality follow-up, we examined whether CKD patients who met the recommended levels of physical activity, sedentary time, and sleep duration had lower mortality risk.
2. Materials and methods
2.1. Data and study participants
The National Health and Nutrition Examination Survey (NHANES) is a cross-sectional study that collects health and nutrition data from the US household population. Participants are selected using a nationally representative stratified random sampling design. By linking NHANES data with the National Death Index (NDI), we prospectively examined whether baseline adherence to the 24-hour movement guidelines was associated with all-cause mortality. The NHANES protocol was approved by the Institutional Review Board of the National Center for Health Statistics and was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants provided written informed consent prior to data collection. Because this study is a secondary analysis of de-identified, publicly available NHANES data, additional approval from a medical ethics committee was not required. From the NHANES datasets (1999–2018), we identified 12,627 participants with CKD who had complete albuminuria and eGFR data. Participants without complete information on 24-hour movement guidelines were excluded (n = 6861). In addition, 188 participants were excluded due to missing survival status or pregnancy. Ultimately, 5578 participants were included in the final analysis. The participant selection process is shown in Figure 1. Missing values for other covariates were imputed using a random forest algorithm. All data used in this study are publicly available at: https://wwwn.cdc.gov/nchs/nhanes/.
Figure 1.
Flowchart of study participants. CKD = chronic kidney disease, NHANES = National Health and Nutrition Examination Survey.
2.2. Definition of CKD
CKD was defined by the diagnostic criteria of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The estimated glomerular filtration rate (eGFR) was calculated using the updated Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The urinary albumin-to-creatinine ratio (UACR), expressed in mg/g, was obtained from spot morning urine samples and used to indicate microalbuminuria. Participants were considered to have CKD if they met either eGFR < 60 mL/min/1.73 m2 or UACR ≥ 30 mg/g.[13]
2.3. Definition of the 24-h movement guidelines
The Canadian 24-Hour Movement Guidelines for adults (≥18 years) provide integrated recommendations for physical activity, sedentary behavior, and sleep duration. Data on moderate-to-vigorous physical activity and SB were collected using the Global Physical Activity Questionnaire, a tool that has been extensively validated across diverse populations. Participants reported their weekly frequency and daily duration of MVPA (e.g., occupational or leisure activities). Adherence to physical activity guidelines was defined as achieving ≥150 minutes of cumulative MVPA per week, with 1 minute of vigorous activity counted as 2 minutes of moderate activity.
SB was characterized by low-energy-expenditure activities (<1.5 METs), such as screen-based leisure, sitting, or reclining while awake. Sedentary time was quantified based on the NHANES PAD680 item: “How much time do you spend sitting during a typical day?” Sleep duration was obtained from self-reported nighttime hours of sleep. Following the guidelines, recommended sleep duration was defined as 7 to 9 hours for adults aged 18 to 64 years and 7 to 8 hours for those aged ≥65 years. These methodologies align with established protocols used in previous NHANES-based studies.[14,15]
2.4. Outcome ascertainment
All-cause mortality was determined using National Death Index records linked to the NHANES dataset, with follow-up through December 31, 2019. The dataset is available at: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/datalinkage/linked_mortality/.
2.5. Assessment of covariates
Covariates include age, sex, race/ethnicity, education level, marital status, poverty income ratio (PIR), eGFR, UACR, body mass index (BMI), smoking status, diabetes, hypertension, alcohol consumption, hyperlipidemia, cardiovascular disease (CVD), and daily energy intake. Specific definitions of covariates are provided in the Supplementary Document, Supplemental Digital Content 2.
2.6. Statistical analysis
The baseline characteristics table presented continuous variables as means with standard error (SE), whereas categorical variables were reported as proportions. For continuous variables, survey-weighted mean (95% CI) and P-value were obtained using survey-weighted linear regression (svyglm). For categorical variables, survey-weighted percentages (95% CIs) and P-values were obtained using the survey-weighted chi-square test (svytable). Table S1, Supplemental Digital Content 1 presents baseline characteristics stratified by age (<65 and ≥65 years). Multivariate Cox regression models were used to estimate adjusted hazard ratios (AHR) and 95% confidence intervals (CIs) for associations with meeting the 24-hour movement guidelines (none, MVPA only, SB only, ST only, MVPA + SB, MVPA + ST, SB + ST). For each outcome (“Survival” or “Death”), the number of guidelines met was recorded. These associations were summarized in a single table, and separate multivariate Cox regression analyses were performed for each. The reference group for all comparisons consisted of participants who did not meet any of the 24-hour movement guidelines. Three models were constructed: model 1 was unadjusted; model 2 was adjusted for age, sex, and race/ethnicity; and model 3 was further adjusted for additional demographic, lifestyle, and health-related variables (education level, marital status, eGFR, UACR, PIR, BMI, smoking status, drinking status, diabetes, hypertension, CVD, hyperlipidemia, and total energy intake) to improve accuracy. Stratified analyses were also performed by sex and age, with results presented separately for each group. All statistical analyses were conducted using R (x64 version 4.3.1; R Foundation for Statistical Computing). A 2-tailed P-value < .05 was considered statistically significant.
2.7. Language editing
During the preparation of this manuscript, the authors used Gemini (Google) and Grammarly (Grammarly) to improve the text’s linguistic quality, readability, and grammatical accuracy. After using these tools, the authors reviewed and edited the content as needed and took full responsibility for the final version of the manuscript.
3. Results
3.1. General characteristics of study participants
Table 1 presents the baseline profiles of participants by their final survival status. While the prevalence of hyperlipidemia was comparable between the 2 groups (P > .05), significant disparities were observed in eGFR, PIR, BMI distribution, diabetes, hypertension, and race/ethnicity (P < .05). Significant differences were observed across groups in terms of eGFR, PIR, BMI distribution, diabetes, hypertension, and race/ethnicity, and these findings remained robust after Benjamini–Hochberg adjustment. Specifically, the surviving cohort was characterized by preserved renal function (higher eGFR) and a lower burden of comorbidities, including diabetes, hypertension, and cardiovascular disease, relative to the deceased cohort. Baseline characteristics stratified by age are further presented in Table S1, Supplemental Digital Content 1.
Table 1.
Baseline characteristics of NHANES participants by final survival status.
| Variables | Overall | Survival status | P-value | P-adjusted | |
|---|---|---|---|---|---|
| Survival | Death | ||||
| N | 5578 | 4176 | 1402 | ||
| Follow-up time, mo | 72.03 ± 1.08 | 76.45 ± 1.31 | 55.48 ± 1.37 | <.0001 | <.0001 |
| eGFR, mL/min/1.73 m2 | 73.89 ± 0.55 | 78.03 ± 0.68 | 58.41 ± 0.86 | <.0001 | <.0001 |
| UACR, mg/g | 188.56 ± 11.03 | 160.11 ± 10.48 | 294.97 ± 33.00 | .0002 | .0002 |
| Energy intake, kcal/d | 1927.50 ± 16.49 | 1975.70 ± 18.11 | 1745.47 ± 19.47 | <.0001 | <.0001 |
| Age, n (%) | <.0001 | <.0001 | |||
| <65 | 2594 (51.00%) | 2339 (58.99%) | 255 (21.12%) | ||
| ≥65 | 2984 (49.00%) | 1837 (41.01%) | 1147 (78.88%) | ||
| Gender, n (%) | .0006 | .0006 | |||
| Male | 2628 (42.85 %) | 1853 (41.52 %) | 775 (47.85%) | ||
| Female | 2950 (57.15%) | 2323 (58.48%) | 627 (52.15%) | ||
| Race, n (%) | <.0001 | <.0001 | |||
| Mexican American | 761 (7.70%) | 641 (8.66%) | 120 (4.14%) | ||
| Other Hispanic | 499 (4.87%) | 417 (5.50%) | 82 (2.52%) | ||
| Non-Hispanic White | 2545 (68.32%) | 1689 (65.66%) | 856 (78.24%) | ||
| Non-Hispanic Black | 1237 (12.02%) | 960 (12.43%) | 277 (10.48%) | ||
| Other race | 536 (7.09%) | 469 (7.75%) | 67 (4.62%) | ||
| Education, n (%) | <.0001 | <.0001 | |||
| Under high school | 1704 (21.44%) | 1179 (19.22%) | 525 (29.71%) | ||
| High school or equivalent | 1312 (25.17%) | 974 (25.06%) | 338 (25.57%) | ||
| College graduate or above | 2663 (53.39%) | 2023 (55.71%) | 539 (44.72%) | ||
| Marital status, n (%) | <.0001 | <.0001 | |||
| Married or living with partner | 2960 (57.21%) | 2296 (59.21%) | 664 (49.74%) | ||
| Living alone | 2618 (42.79%) | 1880 (40.79%) | 738 (50.26%) | ||
| PIR, n (%) | <.0001 | <.0001 | |||
| <1.3 | 1944 (26.06%) | 1424 (24.93%) | 520 (30.28%) | ||
| ≥1.3, <3.5 | 2376 (41.85%) | 1736 (40.39%) | 640 (47.34%) | ||
| ≥3.5 | 1258 (32.09%) | 1016 (34.68%) | 242 (22.38%) | ||
| Smoke, n (%) | <.0001 | <.0001 | |||
| Current smokers | 928 (15.89%) | 687 (15.65%) | 241 (16.77%) | ||
| Nonsmokers | 2792 (50.44%) | 2226 (52.97%) | 566 (40.99%) | ||
| Former smokers | 1858 (33.67%) | 1263 (31.38%) | 595 (42.24%) | ||
| Diabetes, n (%) | <.0001 | <.0001 | |||
| No | 3315 (65.36%) | 2612 (68.54%) | 703 (53.44%) | ||
| Yes | 2263 (34.64%) | 1564 (31.46%) | 699 (46.56%) | ||
| BMI, n (%) | .0393 | .041 | |||
| <25 | 1393 (25.30%) | 976 (24.43%) | 417 (28.57%) | ||
| ≥25, <30 | 1701 (29.40%) | 1271 (29.58%) | 430 (28.73%) | ||
| ≥30 | 2484 (45.30%) | 1929 (45.99%) | 555 (42.70%) | ||
| Drink, n (%) | <.0001 | <.0001 | |||
| Current drinkers | 2755 (56.04%) | 2221 (59.75%) | 534 (42.18%) | ||
| Nondrinkers | 884 (13.48%) | 651 (12.70%) | 233 (16.41%) | ||
| Former drinkers | 1939 (30.48%) | 1304 (27.55%) | 635 (41.41%) | ||
| Hypertension, n (%) | <.0001 | <.0001 | |||
| No | 1222 (25.72%) | 1047 (29.07%) | 175 (13.19%) | ||
| Yes | 4356 (74.28%) | 3129 (70.93%) | 1227 (86.81%) | ||
| CVD | <.0001 | <.0001 | |||
| No | 4133 (77.33%) | 3339 (82.55%) | 794 (57.81%) | ||
| Yes | 1445 (22.67%) | 837 (17.45%) | 608 (42.19%) | ||
| Hyperlipidemia, n (%) | .2501 | .250 | |||
| No | 2359 (41.42%) | 1772 (41.88%) | 587 (39.73%) | ||
| Yes | 3219 (58.58%) | 2404 (58.12%) | 815 (60.27%) | ||
The baseline characteristics table presented continuous variables as means with standard error (SE), whereas categorical variables were reported as proportions.
For continuous variables: survey-weighted mean (95% CI), P-value was by survey-weighted linear regression (svyglm).
For categorical variables: survey-weighted percentage (95% CI), P-value was by survey-weighted chi-square test (svytable).
P-adjusted calculated using the Benjamini–Hochberg method.
BMI = body mass index, CI = confidence interval, CVD = cardiovascular disease, eGFR = estimated glomerular filtration rate, NHANES = National Health and Nutrition Examination Survey, PIR = poverty income ratio, SE = standard error, UACR = urinary albumin-to-creatinine ratio.
Table 2 summarizes the number of individuals meeting each guideline component by survival status, as well as the total number of components followed. Among survivors, 256 individuals (6.13%) did not meet any guidelines, whereas 994 individuals (23.80%) met 3 or more guidelines. Among deceased participants, 154 (10.98%) did not meet any guidelines, whereas 186 (13.27%) met all 3.
Table 2.
Proportion (%) of meeting 24-hour movement guidelines.
| Meeting guidelines | Survival | Death | P-value |
|---|---|---|---|
| General combination, n (%) | 4176 | 1402 | <.001 |
| Guidelines met none | 256 (6.13%) | 154 (10.98%) | |
| Guidelines met 1 of 3 | 1165 (27.90%) | 548 (39.09%) | |
| Guidelines met 2 of 3 | 1761 (42.17%) | 514 (36.66%) | |
| Guidelines met all 3 | 994 (23.80%) | 186 (13.27%) | |
| Specific combination, n (%) | |||
| MVPA only | 121 (2.90%) | 23 (1.64%) | <.001 |
| ST only | 231 (5.53%) | 160 (11.41%) | .330 |
| SB only | 813 (19.47%) | 365 (26.03%) | .014 |
| Guidelines met PA and SB only | 834 (19.97%) | 180 (12.84%) | <.001 |
| Guidelines met PA and ST only | 158 (3.78%) | 23 (1.64%) | <.001 |
| Guidelines met SB and ST only | 769 (18.41%) | 311 (22.18%) | .001 |
MVPA = moderate-to-vigorous physical activity, SB = sedentary behavior, ST = sleep time.
3.2. Association of meeting individual guidelines with all-cause mortality
As shown in Figure 2, participants adhering only to the MVPA guideline had significantly lower mortality risk compared with those who did not meet any guideline (model 1: HR = 0.37, 95% CI: 0.24–0.57; model 2: HR = 0.42, 95% CI: 0.27–0.65; model 3: HR = 0.48, 95% CI: 0.29–0.79). Adherence to sedentary time recommendations alone was also associated with reduced mortality risk (model 1: HR = 0.70, 95% CI: 0.58–0.85; model 2: HR = 0.72, 95% CI: 0.60–0.87; model 3: HR = 0.75, 95% CI: 0.61–0.92). Adherence to sleep guidelines alone showed no significant association with mortality across all 3 models.
Figure 2.
Associations of meeting 24-hour movement guidelines with all-cause mortality. CI = confidence interval, MVPA = moderate-to-vigorous physical activity, SB = sedentary behavior, ST = sleep time.
3.3. Association of meeting specific guideline combinations with all-cause mortality
Compared with participants who did not adhere to any guidelines, adherence to combined guideline categories was associated with lower mortality risk: SB + ST (model 3: HR = 0.67, 95% CI: 0.54–0.83), MVPA + ST (model 3: HR = 0.42, 95% CI: 0.26–0.69), and MVPA + SB (model 3: HR = 0.47, 95% CI: 0.37–0.61; Fig. 2).
3.4. Association of the number of guidelines met with all-cause mortality
When comparing all-cause mortality across adherence groups, participants who met all 3 guidelines (model 3: HR = 0.45, 95% CI: 0.36–0.57), 2 guidelines (model 3: HR = 0.58, 95% CI: 0.47–0.70), or 1 guideline (model 3: HR = 0.78, 95% CI: 0.65–0.94) had a significantly lower risk of all-cause mortality compared with those who did not meet any of the 24-hour movement guidelines.
3.5. Subgroup analysis stratified by sex
As shown in Figure 3, multivariable Cox regression analyses were performed stratified by sex (male and female), with adjustment for all covariates included in model 3. In all studies, participants who did not meet any guideline were used as the reference group. Results were largely consistent with the main findings: the ST-only group showed no significant association, whereas other groups demonstrated varying degrees of reduced all-cause mortality risk.
Figure 3.
Associations between adherence to the 24-hour movement guidelines and all-cause mortality, stratified by sex. CI = confidence interval, MVPA = moderate-to-vigorous physical activity, SB = sedentary behavior, ST = sleep time.
3.6. Subgroup analysis stratified by age
We further stratified the Cox regression analyses by age (<65 and ≥65 years) and adjusted for the same covariates as in model 3. As shown in Figure 4, among participants aged 65 years or older, the results were consistent with the main findings: all combinations were associated with reduced all-cause mortality compared with those meeting no guidelines, except for the ST-only group, which showed no significant association. In contrast, among participants <65 years, no statistically significant association was observed between adherence to any single or combined guideline and all-cause mortality. Meeting MVPA guidelines (HR = 0.60, 95% CI: 0.18–1.98) or MVPA + SB (HR = 0.67, 95% CI: 0.35–1.29) suggested a potential protective trend, whereas adherence to ST guidelines alone indicated an increased risk (HR = 2.01, 95% CI: 0.99–4.08). However, none of these associations reached statistical significance. When examining the number of guidelines met, hazard ratios showed a progressive downward trend with increasing adherence (1 guideline: HR = 1.16, 95% CI: 0.67–2.02; 2 guidelines: HR = 0.84, 95% CI: 0.48–1.47; 3 guidelines: HR = 0.68, 95% CI: 0.37–1.26).
Figure 4.
Associations between adherence to the 24-hour movement guidelines and all-cause mortality, stratified by age. CI = confidence interval, MVPA = moderate-to-vigorous physical activity, SB = sedentary behavior, ST = sleep time.
4. Discussion
In this analysis of survival outcomes among NHANES participants with CKD, adherence to the 24-hour movement guidelines (≥150 min/wk of moderate-to-vigorous physical activity, reduced sedentary time, and recommended sleep time) was associated with significantly lower all-cause mortality in both the overall cohort and participants aged ≥65 years. This reduction was observed for each guideline component, individually and in combination, except for sleep time alone, which showed no significant association. Conversely, among participants <65 years, no statistically significant survival benefit was observed with adherence to guidelines, and several hazard ratios exceeded 1.0. These findings suggest a potential age-specific effect: older CKD patients who adhered to the movement guidelines demonstrated a clear survival benefit, whereas younger patients did not exhibit comparable benefits.
Our findings are generally consistent with the existing literature, while also highlighting novel age-specific differences. Specifically, adherence to physical activity guidelines was associated with significantly reduced mortality among CKD patients aged ≥65 years. This finding aligns with evidence from an extensive Korean community-based cohort study of older adults, which reported that high physical activity was associated with a 24% lower mortality risk (HR = 0.76).[16] An extensive global study involving more than 2 million participants reported that meeting physical activity recommendations was associated with an approximately 22% lower risk of all-cause mortality, with greater benefits observed among older adults.[17] These findings suggest that physical activity confers more pronounced survival benefits in older adults, which may partly explain the absence of significant effects among younger CKD patients. Similarly, for sedentary behavior, reduced sitting time – consistent with sedentary time guidelines – was associated with improved survival among older CKD patients. This finding is consistent with previous studies, which reported that CKD patients sitting for more than 6 hours per day had a 1.64-fold higher risk of all-cause mortality.[6] In the general population, individuals with the highest sitting time (≈13 h/d) have nearly twice the mortality risk compared with those with the lowest sitting time.[18] Regarding sleep, we found that older CKD patients adhering to the 7 to 8-hour sleep guideline had lower mortality, consistent with epidemiological evidence showing a U-shaped association between sleep duration and mortality. A meta-analysis in older populations showed that prolonged sleep (≥9 hours) was associated with a significantly higher risk of all-cause mortality, whereas short sleep (<6 hours) had a weaker effect.[19] Similarly, a Japanese cohort study of individuals with CKD reported that sleeping ≥9 h/night was associated with a higher risk of CKD-related mortality (HR = 1.82), and this association was particularly pronounced among participants younger than 65 years.[20] In contrast, no significant association was observed between sleep duration and all-cause mortality in our younger cohort, which may be attributable to differences in study endpoints (CKD-specific vs all-cause mortality) or sample characteristics. Importantly, beyond individual behaviors, evidence from other studies suggests that comprehensive adherence to the 24-hour movement guidelines provides additive benefits. For example, Liu et al reported that meeting multiple guideline recommendations (physical activity, sedentary behavior, and sleep) was associated with a 40% to 60% reduction in the risk of frailty.[14] Chinese older adults who adhered to multiple guideline recommendations were less likely to report depressive symptoms and feelings of loneliness.[21] Our study extends the existing literature by demonstrating that comprehensive adherence to the 24-hour movement guidelines yields survival benefits primarily among older CKD patients. In contrast, younger patients show no significant associations and, in some cases, even exhibit HR > 1. This highlights a distinct age-specific discrepancy that has not been widely documented.
Our study revealed pronounced age-related subgroup differences, which may be attributable to several factors. Older patients with CKD often experience more pronounced “inflammaging” and immune senescence,[22,23] as well as longer disease duration and a greater comorbidity burden. The aging kidney and immune system are more sensitive to stressors, which may render physical activity more impactful on health outcomes. Furthermore, the all-cause mortality rate was significantly higher in the older subgroup than in the younger group, thereby providing greater statistical power to detect associations. Among younger CKD patients (age < 65), particularly those in the reference group (0 guideline-compliant), relatively few deaths occurred (17/143 = 11.89%), which may have limited the ability to detect significant HR reductions and increased the likelihood of type II errors.[24] Even if guideline adherence reduces risk in younger individuals, the low baseline event rate diminishes the absolute risk reduction and widens confidence intervals, potentially rendering HRs nonsignificant. Statistically, when the control group has a low mortality rate, HRs tend toward null even if an intervention provides protection. Thus, HRs that appear ineffective or slightly above 1 in younger cohorts may reflect low baseline risk rather than actual harm from the intervention.
The strengths of this study include the use of NHANES, a large-scale, nationally representative survey of the US population. Linkage with the NDI provided complete follow-up data on all-cause mortality through 2019. We assessed three 24-hour movement behaviors (physical activity, sedentary time, and sleep) in accordance with Canadian guidelines, enabling a comprehensive analysis of the “all-day” activity profile. Additionally, we conducted stratified analyses by age (<65 vs ≥65 years) and sex, recognizing that guideline recommendations and risk profiles vary by demographic subgroup. Finally, we adjusted for numerous covariates (demographics, CKD severity, comorbidities, diet, etc), which attenuated – but did not eliminate – the influence of confounding.
Nevertheless, several limitations should be acknowledged. First, this is an observational study, which inherently limits the ability to make causal inferences. As in other cohort studies of lifestyle behaviors and mortality, our exposure variable was measured only once at baseline and examined prospectively for associations. A single baseline measurement cannot capture changes in behavior over time, potentially attenuating true associations. Second, all movement behaviors were self-reported, making them susceptible to recall bias and social desirability bias. Third, residual confounding cannot be excluded despite extensive covariate adjustment. Finally, the limited number of mortality events in the younger subgroup (<65 years) constrained statistical power. Therefore, null findings in this subgroup should be interpreted with caution, as the small number of events may have widened confidence intervals and obscured true associations.
Future research should aim to elucidate causal relationships and underlying mechanisms. Specifically: Prospective cohort studies and intervention trials are needed. Longitudinal studies with repeated assessments of physical activity could clarify whether long-term adherence to physical activity influences outcomes, whereas randomized exercise trials would provide stronger causal evidence. Objective measures of activity and sedentary time should be incorporated, as device-based monitoring provides more accurate exposure data. Research should investigate biological mediators linking activity with mortality. For example, physical activity reduces chronic inflammation and improves cardiovascular health, which may slow CKD progression and lower mortality risk. Future studies could measure inflammatory biomarkers, endothelial function, or renal function trajectories to elucidate these mechanisms. Researchers should also examine outcomes beyond mortality. Quality of life, functional status, and cardiovascular events are critical endpoints in CKD. Intervention studies should further evaluate age-specific strategies, as our stratified analyses indicate that younger and older CKD patients may respond differently. Such studies will help translate these findings into tailored guidelines effective for patients with CKD across age groups.
5. Conclusions
Among adults with CKD, adherence to the Canadian 24-Hour Movement Guidelines was associated with lower all-cause mortality. The protective effect was most evident in older adults (≥65 years). These findings suggest that integrated movement behaviors may improve survival in CKD; however, longitudinal and interventional studies are needed to confirm these associations and to clarify potential age-specific effects.
Author contributions
Data curation: Huan Zou.
Formal analysis: Huan Zou.
Methodology: You Zhang.
Software: Huan Zou.
Supervision: You Zhang.
Validation: You Zhang.
Writing – original draft: Huan Zou, You Zhang.
Writing – review & editing: You Zhang.
Abbreviations:
- BMI
- body mass index
- CI
- confidence interval
- CVD
- cardiovascular disease
- eGFR
- estimated glomerular filtration rate
- HR
- hazard ratio
- MVPA
- moderate-to-vigorous physical activity
- NHANES
- National Health and Nutrition Examination Survey
- PIR
- poverty income ratio
- SB
- sedentary behavior
- ST
- sleep time
- UACR
- urinary albumin-to-creatinine ratio
The NHANES protocol was approved by the Institutional Review Board (IRB) of the National Center for Health Statistics (NCHS) and was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants provided written informed consent prior to data collection. Because this study is a secondary analysis of de-identified, publicly available NHANES data, additional approval from a medical ethics committee was not required.
The authors have no funding and conflicts of interests disclose.
The datasets generated during and/or analyzed during the current study are publicly available.
Supplemental Digital Content is available in the online version of this article (http://dx.doi.org/10.1097/MD.0000000000049610).
How to cite this article: Zou H, Zhang Y. Does adherence to Canadian 24-Hour Movement Guidelines reduce all-cause mortality in patients with chronic kidney disease? Medicine 2026;105:27(e49610).
During the preparation of this work, the authors used Gemini and Grammarly in order to improve the English language and writing style. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
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