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Table 2. Proportions Reporting MSE ≥ 2 Times/Week and AORs a for Meeting the Recommendations ( continued)

Met MSE recommendations ( ≥ 2 times/week) Weighted % b ( 95%

Characteristics n CI) AOR a( 95 % CI)

Fair 52,953 18.3 (17.6, 19.0) 0.50 (0.46, 0.53)

Poor 20,664 14.7 (13.8, 15.7) 0.45 (0.41, 0.50)

Smoking status
Current (daily) 40,236 21.1 (20.3, 21.9) 0.72 (0.68, 0.76)

Current (some days) 16,440 30.5 (29.1, 31.8) 0.99 (0.91, 1.07)
Former smoker 114,649 28.5 (28.0, 29.1) 1.03 (0.99, 1.07)

Never smoked 223,858 32.6 (29.9, 30.5) 1.00 (ref)

Note: Boldface indicates statistical signi fi cance ( p< 0.05).
a Adjusted for all other explanatory variables in the table.

bData weighted using stratum weight provided by the Centers for Disease Control and Prevention. 57 c To meet the aerobic recommendations a respondent had to report ≥ 150 moderate-intensity
minutes/week or ≥ 75 vigorous-intensity minutes/week or an equivalent combination of both.

MSE, muscle-strengthening exercise.

The ORs ranged from 0.70 (95% CI=0.67,0.73) for very good to DISCUSSION
0.45 (95% CI=0.41, 0.50) among those reporting poor health. The key fi nding is that among approximately 400,000
Compared with never smokers, current daily smokers had 28% lower U.S. adults, more than half do not engage in MSE. Considering the independent
odds of meeting the MSE recommendations. health bene fi ts associated with MSE, 58 the current fi ndings are concerning from
a public health perspective. Another key fi nding
After adjusting for potential confounders (e.g., age, sex, aerobic is that MSE was independently associated with lower odds of
MVPA, smoking, BMI), compared with those who did no MSE, no prevalent diabetes, obesity, and cancer (non-skin), although dose − response was not
frequencies were associated with a lower risk of coronary heart disease ( always evident.
Figure 1 ). For diabetes, there was a U-shaped association, with the
lowest odds among those reporting MSE This study showed a similar MSE prevalence to previous U.S. data.
three to four times/week (OR=0.69, 95% CI=0.63, 0.76). Only those Data from BRFSS 2011 estimated that
reporting MSE either one (OR=0.91, 95% CI=0.83, 0.99) or two 29.3% of U.S. adults met the MSE recommendations, 44

times/week (OR=0.89, 95% CI=0.81, 0.98) had lower odds of a cancer (0.9% lower than prevalence estimates), suggesting that MSE levels among
(non-skin) diagnosis (data are shown in U.S. adults appear to be stable over 4 years (2011 − 2015).
Similar MSE levels have been observed in the United Kingdom, 45 whereas lower
levels are reported among Australian 28,43 and Finnish adults 42
Appendix Table 1 , available online).
Compared with those who did no MSE, there were reduced odds of
(range, 10% − 20%). Interestingly, one study in the U.S. estimated
reporting poor self-rated health across all MSE frequencies (Table 3). The
approximately 6% of the population met the MSE recommendations. 59 In this
ORs showed a Ushaped association, with a relative increase in
study, among 4,000 adults, not only was frequency of MSE assessed, but in
the odds among those reporting the highest MSE frequency ( fi ve or more
accordance with the U.S. guidelines, 7 all seven major muscle groups had to be
times/week). There was a linear decrease in the odds of being classi fi ed
targeted (i.e., shoulders, arms, back, chest, abdomen, legs, and hips). 59
obese across all MSE frequencies. This ranged from 24% among those
Discordance in prevalence estimates suggest the need to test the validity of MSE
reporting MSE one time/week to 44% among those reporting fi ve or more
instruments used in surveillance studies.
times/week.

The sociodemographic and lifestyle-related MSE correlates observed in

the present study were generally consistent with previous studies. Others
For stroke, there was no signi fi cant change in odds among those
identify that females, older adults, not meeting the aerobic
reporting lower MSE frequencies. However, among the
recommendations, being obese/overweight, lower income/education, and
highest frequency there were 19% increased odds. When strati fi ed by sex,
smoking are inversely associated with
age, and BMI, the increased odds remained signi fi cant only for those with
meeting MSE recommendations. 28,42 , 43,45 These fi ndings underscore the
a BMI classi fi ed as obese (OR=1.30, 95% CI=1.03,
importance of targeting these population
1.63; Appendix Table 2 , available online).

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Figure 1. AORs for adverse health outcomes according to muscle-strengthening exercise (times/week) (reference=0 times/week) among 2015 Behavioral Risk Factor
Surveillance System sample ( n= 397,423). Bars, 95% CI.
Note: Data are shown in Appendix 1 (available online).
a Adjusted for sex, age, race/ethnicity, employment, education, income, moderate-to-vigorous intensity aerobic activity, smoking, and BMI.
b Adjusted for sex, age, race/ethnicity, employment, education, income, moderate-to-vigorous intensity aerobic activity, and smoking.
c To be classi fi ed as being diagnosed with coronary heart disease, diabetes, stroke, or cancer (non-skin) a respondent had to report having a “ doctor, nurse or other health professional ” diagnose

each condition.
d Self-rated health and BMI based on self-report.

subgroups in future MSE public health interventions. In particular,
because the lowest odds for meeting the MSE recommendations were
observed among older adults, community-based interventions should speci fi
cally target this population subgroup. The fi ndings on MSE levels across
different racial groups was somewhat surprising. For example, in contrast to
research on correlates of aerobic MVPA, this study showed that black, non-
23
Hispanics and multiracial,
non-Hispanics were more likely to meet the MSE guidelines, when
compared with white adults. These fi ndings are suggestive that MSE
might be a particularly popular activity among non-white population
subgroups. This could be important for future MSE interventions that
target currently inactive black and multiracial populations.
Compared with BRFSS 2015 respondents who reported no aerobic MVPA
(24.6%), more than twice as many respondents reported no MSE (57.8%).
Public health action is warranted to support MSE uptake/adherence.
However, contrasted with MVPA, MSE has unique health promotion
challenges. First, MSE requires a rudimentary understanding of speci fi c
nomenclature (e.g., sets, repetitions, large muscle groups) and access to some
basic equipment (e.g., resistance bands, dumbbells). 10 Second, this behavior
requires self-ef fi cacy to perform MSE-
related activities (e.g., push-ups, squats, sit-ups, and lunges). 60 Last,
negative social norms associated with MSE might be impeding its uptake,
as this activity might be associated with excessive muscle
gain, risk of injury, and hyper-masculine settings (e.g., gymnasiums). 57
, 60 − 62
To address these complex MSE promotion issues, a coordinated social
ecologic approach is warranted. 63
Potential concurrent public health strategies based on limited research may
include some of the following approaches: increasing the availability of
MSE equipment for home-based activity (e.g., resistance bands, barbells),
64 establishing affordable/attractive spaces to perform MSE (e.g., fi tness
centers, apparatuses in open community spaces), 65,66 use of behavior-
change science techniques to understand how different activities suit
different groups, 67 public access to professionals who have skills in
prescribing and teaching MSE (e.g., strength coaches/ fi tness instructors),
68 mass media campaigns endorsing MSE as important for overall physical
activity and health, and challenging the negative social norms sometimes
associated with this activity. 69
Strengths of this study include the use of a large, nationally
representative sample of U.S. adults. Moreover, MSE levels were
examined across a wide variety of sociodemographic and
lifestyle-related categories.

Additionally, the use of standardized data collection makes it

possible to compare fi ndings to future BRFSS results.
Limitations

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Given the cross-sectional design, the authors are cautious in drawing

are now needed to con fi rm the preliminary fi ndings on the
strong inferences from the associations observed between MSE and
association between weekly frequency of MSE and health
adverse health conditions. Notwithstanding this limitation, apart from
outcomes. Another limitation was the use of a single self-report item
stroke, when compared with those who did none, any MSE participation
assessing weekly MSE frequency. Although the item has
was generally associated with lower odds for a set of common adverse
acceptable reliability, 51 the
health outcomes. However, the U-shape association for diabetes, cancer,
authors are unable to eliminate the possibility of selfreport bias, which
and poor self-rated heath suggests that low-to-moderate MSE frequencies
may have led to overestimation of MSE in the present study. Because
might be more effective in reducing the risk of these
MSE duration and intensity were not assessed, the authors are unable
adverse health conditions. Potential explanations may be the
to determine how these might have in fl uenced the adverse health
pathophysiologic consequences associated with chronic MSE
conditions. Last, MSE was unlikely to be captured during gardening,
overtraining (e.g., chronic in fl ammation, immunosuppression, and
yard work, or laboring. However, given that over the past 50 years
musculoskeletal discomfort/pain). 70 For obesity, there was an inverse
technologic advancements have resulted in a decline in energy
linear association between this outcome and MSE. Longitudinal
expenditure within household/occupational domains, 71 it is unlikely
evidence has shown a linear dose
that many adults engage in suf fi cient MSE within these contexts.

− repose relationship between minutes per week spent in MSE and

reduction in gain in waist circumference among approximately 10,000
healthy males. 36
CONCLUSIONS
Somewhat surprising were the fi ndings that the highest MSE
frequency ( fi ve or more times/week) was associated with an More than half of U.S. adults do not engage in MSE. For maximal

increased odds of stroke. This might be explained by the increased public health bene fi ts, effort should be made to enable greater

risk of arterial stiffness 40 and hypertension among speci fi c populations proportions of the population to increase their involvement in MSE.

who engage in high levels/intensity of MSE (e.g., athletes). 41 Moreover, a Comprehensive public health strategies are needed to promote

recent prospective study of approximately 30,000 older women showed a population-level MSE uptake/adherence. Future MSE public health

reverse J-shaped nonlinear association between MSE and interventions should target older adults, females, and those with low

all-cause mortality. 37 In the strati fi ed analyses, the increased risk of education/income.

stroke remained solely among the obese, suggesting caution in

encouraging high levels of MSE among this group. Nevertheless, because
most adults do no MSE, it is unlikely that too much MSE poses a signi fi
cant public health risk. Regardless, future interventions should promote
low-to-moderate MSE participation levels, as
ACKNOWLEDGMENTS
We thank all 2015 Behavioral Risk Factor Surveillance System participants for their
generous contributions. We thank Taryn Axelsen from USQ Statistical Consulting
Unit for her initial advice on the data analysis.

opposed to high levels.

No fi nancial disclosures were reported by the authors of this paper.

A key limitation was the cross-sectional design restricting the
possibility of inferring causality. The authors are unable to rule out
reverse causality, for example, the reduced odds of adverse health
outcomes may be because of the fact that individuals with health
conditions are less likely to participate in exercise, including MSE.
Alternatively, it might be possible that those with existing health
conditions could engage in MSE more frequently than those
without such conditions, potentially because their health
complications motivate them to do so (e.g., rehabilitation for
diabetes, cancer, stroke). Future studies with prospective designs
SUPPLEMENTAL MATERIAL
Supplemental materials associated with this article can be found in the online
version at https://doi.org/10.1016/j. amepre.2018.07.022 .
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