ArticleDialogues in health2026
Structural physical activity restriction, cerebrovascular and diabetes mortality, and long-term care intensity in Japan: An ecological panel study across 47 prefectures (2013-2022) with a COVID-19 counterfactual analysis.
Article in Dialogues in health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Physical inactivity is an established cardiovascular risk factor at the individual level, but the population-level mortality cost attributable to modifiable, built-environment constraints on daily physical activity - rather than to individual behaviour - has lacked an empirical benchmark, leaving investment in walkable urban design without a clear health-economic case. We asked whether structurally constrained population physical activity is associated with cause-specific mortality, and used the 2020 COVID-19 mobility restriction - a society-wide curtailment that could never be imposed experimentally - to estimate the effect size of an acute collective PA shock on cardiovascular and metabolic deaths. Methods: 10-year ecological panel of Japan's 47 prefectures (2013-2022; Results: Higher car-only commuting (range 8.5-79.0%) was associated with greater CVD (IRR per SD = 1.064; 95% CI 1.037-1.093; +29% across the observed range) and DM mortality (IRR = 1.030; 1.000-1.060), and with greater long-term-care severity (SHR OR = 1.39; 1.18-1.64). CVD persisted across all five adjustment models; DM attenuated to non-significance after consumption-expenditure adjustment, consistent with a correlated socioeconomic cluster rather than an independent driver. In 2020, the most car-dependent tertile recorded +8.3% excess CVD deaths (95% CI +2.8% to +14.0%) versus near-zero excess elsewhere - a quantifiable effect of acute collective PA restriction on cardiovascular mortality. Conclusion: A modifiable feature of modern life - car dependence - carries a measurable population-level cardiovascular mortality cost that amplifies when behavioural PA is acutely curtailed. The effect size justifies treating walkable urban design and public transit as primary NCD prevention in super-ageing societies, not as ancillary transport policy. Funding: None declared.
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