Economic burden of cardiovascular disease attributable to no muscle‑strengthening exercise

Aims
To quantify annual U.S. cardiovascular disease costs attributable to absence of muscle‑strengthening exercise and to describe variation by condition, age, and sex.

Methods
A population attributable fraction framework combined etiologic risk from cohort meta‑analyses (any muscle‑strengthening exercise versus none pooled relative risk 0.83; inverted to 1.20, 95% CI 1.10–1.37 for no muscle‑strengthening exercise), national prevalence of no muscle‑strengthening exercise from the Behavioral Risk Factor Surveillance System (57.2%), and American Heart Association cost envelopes for 2017–2020. The attributable fraction was applied to national and per‑person direct health care, indirect productivity, and combined costs. One‑way sensitivity analysis varied prevalence by ± 10%.

Results
The fraction of cardiovascular disease burden attributable to no muscle‑strengthening exercise was 10.27% (95% CI 5.41%–17.47%). Annual national costs attributable to no muscle‑strengthening exercise were 27.43 billion USD in direct spending, 18.11 billion USD in indirect losses, and 45.54 billion USD combined. Per‑person attributable costs were 214 USD for direct care, 142 USD for indirect losses, and 356 USD combined. Sensitivity analysis yielded combined national costs of 41.38–49.58 billion USD and per‑person costs of 323–388 USD. Condition‑specific estimates indicated the highest per‑person burden for stroke, followed by heart failure. Women had higher per‑person costs than men for coronary heart disease and atrial fibrillation, and costs increased steadily with age.

Conclusions
Absence of muscle‑strengthening exercise contributes materially to U.S. cardiovascular disease spending and productivity losses. Increasing engagement from zero to some strength training may produce medical cost offsets and societal benefits. The total burden is likely underestimated because informal care and other nonmedical costs are not captured.