Article Text

Original research
Active living environments, physical activity and premature cardiometabolic mortality in Canada: a nationwide cohort study
  1. Sarah M Mah1,
  2. Claudia Sanmartin2,
  3. Mylène Riva1,3,
  4. Kaberi Dasgupta4,5,
  5. Nancy A Ross1
  1. 1Department of Geography, McGill University, Montreal, Quebec, Canada
  2. 2Statistics Canada, Ottawa, Ontario, Canada
  3. 3Institute for Health and Social Policy, McGill University, Montreal, Quebec, Canada
  4. 4Department of Medicine, McGill University, Montreal, Quebec, Canada
  5. 5Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
  1. Correspondence to Dr Nancy A Ross; nancy.ross{at}


Objective To evaluate sex-specific and age-specific associations of active living environments (ALEs) with premature cardiometabolic mortality.

Design Population-based retrospective cohort study.

Setting Residential neighbourhoods (1000-metre circular buffers from the centroids of dissemination areas) across Canada for which the Canadian ALE Measure was derived, based on intersection density, points of interest and dwelling density.

Participants 249 420 survey respondents from an individual-level record linkage between the Canadian Community Health Survey (2000–2010) and the Canadian Mortality Database until 2011, comprised of older women (65–85 years), older men (65–81 years), middle-aged women (45–64 years) and middle-aged men (45–64 years).

Primary outcome measures Premature cardiometabolic mortality and average daily energy expenditure attributable to walking. Multivariable proportional hazards regression models were adjusted for age, educational attainment, dissemination area-level median income, smoking status, obesity, the presence of chronic conditions, season of survey response and survey cycle.

Results Survey respondents contributed a total of 1 451 913 person-years. Greater walking was observed in more favourable ALEs. Walking was associated with lower cardiometabolic death in all groups except for middle-aged men. Favourable ALEs conferred a 22% reduction in death from cardiometabolic causes (HR 0.78, 95% CI 0.63 to 0.97) for older women.

Conclusions On average, people walk more in favourable ALEs, regardless of sex and age. With the exception of middle-aged men, walking is associated with lower premature cardiometabolic death. Older women living in neighbourhoods that favour active living live longer.

  • public health
  • epidemiology
  • social medicine

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:

View Full Text

Statistics from

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Contributors SMM, CS, KD and NAR conceptualised the study design. SMM, CS and NAR had full access to the data in the study. SMM performed the statistical analysis. SMM drafted the manuscript. All authors (SMM, CS, KD, MR and NAR) contributed to the data interpretation and revised drafts of the manuscript for important intellectual content. SMM and NAR are the guarantors.

  • Funding This study was funded by the Canadian Institutes of Health Research–Institute of Population and Public Health, through the Data Analysis Existing Databases Operating Grant, grant #410 289. SMM was supported by the Fonds de Recherche du Québec Santé Doctoral Training Award (grant number not applicable). NAR is funded by the Canadian Institutes of Health Research Canada Research Chairs Program.

  • Disclaimer Funding organisations had no role in the study design, data analysis, interpretation of data, writing of the manuscript and the decision to submit the article for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The Canadian Community Health Survey was conducted by Statistics Canada. Ethics approval, and consent to participate in the survey was obtained by Statistics Canada. All analyses were conducted under project number 16-HAD-MCG-4802 at the McGill University site of the Canadian Research Data Centre Network, a secure laboratory which provides access to micro-data holdings of Statistics Canada and has in place a detailed protocol to protect the confidentiality of respondents. Consistent with this protocol, all frequencies have a rounding base to the nearest five respondents, and tabulations resulting in cell-counts under 50 individuals were not released.

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

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data from the Canadian Community Health Survey are available from Statistics Canada for researchers who meet the criteria for access to confidential data. Details can be found at the Statistics Canada Research Data Centres website. See:

  • 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.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.