Independent and joint associations of volume and intensity of physical activity on cognitive impairment among middle-aged and elderly Chinese adults: A national longitudinal study

Wei Yin; Yan Han; Hongmei Sun

doi:10.1371/journal.pone.0339124

Peer Review History

Original SubmissionJuly 22, 2025
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Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: No ****** Reviewer #1: This is an interesting paper on physical activity and cognitive impairment in middle and older adults in China. It is a well-organized paper with a good literature review, statistical rigor, and discussion. A general comment would be that there are a lot of abbreviations within the abstract. It’d be good if you could summarize those to make it more interesting to read, especially the results part. In the literature review, lines 95-96 cite an article about machine learning and depression, not sure how that is relevant to the sentence there. Please revise that. Line 125, there is an abbreviation “ID” without a previous explanation. Please review that. In lines 172-182, phrases like ‘such as’, ‘including…’ are used, and this might indicate there are more variables listed below, so rephrase it (unless there are more variables not mentioned in that paragraph) Reviewer #2: In general, the language is good. however there are some areas for suggested improvement. minor edits only: in the abstract: Suggest "....and their combined risk for cognitive impairment", rather than "their combination" In the introduction, a suggestion to define cognitive impairment in the context of the study from the outset. Define what exactly this study is examining- cognitive impairment or dementia (which is a major neurocognitive disorder) cognitive impairment should ideally be delineated in terms of mild, moderate or severe, which dementia is an example of. NB in line 87 the study appears to examine neurodegenerative disorders. line 79, " The World Health Organization (WHO) recommends 150-300 minutes of moderate-intensity physical activity per week, 75-150 minutes of vigorous-intensity physical activity, or some equivalent combination of moderate intensity and vigorous-intensity aerobic physical activity per week. " suggest the authors indicate what exactly for? to maintain a good physique/remain healthy/ avoid dementia, prevent various illnesses? line 106-108: check grammar. suggest "utilized" or motivate for the study adequately. line 126-129: suggest full stop after the word "baseline" in "There were 489 data with positive cognitive impairment at 127 baseline. then: "Twenty five with missing data in PA and cognitive impairment data at baseline were excluded, and 1487 with missing data in longitudinal cognitive impairment data were excluded, leaving 11262 data." line 145, revise sentence to indicate what is "calculated as follows"? the MET score? if so, state this clearly. line 149, suggest "therefore, we elected to divide the results according into two main categories...." line 156: suggest "domains" or "functions" not "abilities" line 165: suggest 'similar to" rather than "as" (in comparing the TICS and the MMSE) line 176: insert "are" between "(BMI)" and categorized" ****** what does this mean? ). 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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. Attachments Attachment Submitted filename: PONE-D25-38561 REVIEW.docx https://doi.org/10.1371/journal.pone.0339124.r001
Revision 1
10 Nov 2025 Author Response Response by Wei Yin and Hongmei Sun et al. Ref: PONE-D-25-38651 Title: Independent and joint associations of volume and intensity of physical activity on cognitive impairment among middle-aged and elderly Chinese adults: a national longitudinal study PLOS ONE Dear Dr. Sun, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Dec 12 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Demitri Constantinou, MD Academic Editor PLOS ONE HANDLING EDITOR Comments Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Response: Many thanks to the editor for your kind words and the chance for revision submission. We have carefully revised it in accordance with all the reviewers’ comments. Below, we provide point-by-point responses to their feedback. The reviewers’ comments are displayed in blue, our responses in black, and additions to the revised manuscript are highlighted in red. Reviewer #1: PLOS ONE Ref: PONE-D-25-38651 Title: “Independent and joint associations of volume and intensity of physical activity on cognitive impairment among middle-aged and elderly Chinese adults: a national longitudinal study” This is an interesting paper on physical activity and cognitive impairment in middle and older adults in China. It is a well-organized paper with a good literature review, statistical rigor, and discussion. Response: We sincerely thank the reviewer for the insightful and encouraging comments. We truly appreciate your recognition of the novelty and public health significance of our study. We have carefully addressed each of your suggestions and have revised the manuscript to improve the clarity of writing and ensure overall structural completeness. Detailed point-by-point responses are provided below. We hope the revised manuscript and our responses satisfactorily address your concerns and meet your expectations. Comment 1: A general comment would be that there are a lot of abbreviations within the abstract. It’d be good if you could summarize those to make it more interesting to read, especially the results part. Response: We thank the reviewer for this valuable comment. We have summarized abbreviations to make it more interesting to read within the abstract. Then, we have provided the full name for each abbreviation upon its first appearance. (Abstracts section, page 2, lines 36-56). The revised paragraph now reads as follows: Abstracts Background: The objective of this study was to explore the longitudinal relationship between the volume and intensity of physical activity (PA) and their combined risk for cognitive impairment (CI). Methods: The study included 10,174 participants from the 2011-2018 CHARLS cohort. PA and CI were assessed using self-reported questionnaires. Statistical analyses were performed using the Cox regression model. Results: After adjusting for all covariates, the risk of CI was 14% lower in subjects with physical activity volume (PAV) ≥600 Metabolic Equivalent of Task (MET)-min/week compared to those with insufficient PA (HR: 0.86). The risk was reduced by 38% for subjects with PAV of 1800-2999 MET-min/week (HR: 0.62). Regarding the intensity of PA, the risk of CI was reduced by 25% for a proportion of 0.25-0.5 of (moderate to vigorous PA) MVPA to PAV (HR: 0.75) compared to a proportion of 0-0.25. Regardless of PAV, the risk of CI was lowest when the proportion of moderate to vigorous PA(MVPA) to PAV was 0.25-0.5, and 0.5-0.75 for the proportion of light-intensity physical activity (LPA) to PAV. Conclusion: The PAV 1800-2999 MET-min/week and maintaining a proportion of LPA to PAV of 0.5-0.75, or a proportion of MVPA to PAV of 0.25-0.5, are more effective in reducing the risk of CI. Policy implications should prioritize tailored physical activity strategies for individuals over 65, emphasizing low-intensity activities, safe high-intensity training, and the development of accessible urban facilities, in line with WHO guidelines. Comment 2: In the literature review, lines 95-96 cite an article about machine learning and depression, not sure how that is relevant to the sentence there. Please revise that. Response: We appreciate this suggestion. We have removed the article about machine learning and depression in the literature review, and we have added the new references. (Introduction section, page 4, lines 95-97). The revised paragraph now reads as follows: “Introduction …Survey To the best of our knowledge, specific guidelines for PA to prevent the onset of cognitive impairment remain absent. Furthermore, the causal relationship between PA and cognitive functioning is still a subject of debate in the existing research. One study observed engaging in high-intensity PA may lead to cognitive decline in middle-aged and older adults [20], whereas another study found that moderate-to-high intensity aerobic physical activity did not slow cognitive impairment in people with mild-to-moderate dementia [21]. …” The relevant certificate involved is listed as follows: 20. Temesgen, W.A., H.Y. Cheng, and Y.Y. Chong, Cognitive function and its longitudinal predictability by intensity of physical activity in Chinese middle-aged and older adults. J Alzheimers Dis, 2025. 103(3): p. 809-820. Comment 3: Line 125, there is an abbreviation “ID” without a previous explanation. Please review that. Response: Thanks for your valuable advice. We have revised the abbreviation “ID” to “identity document”. Thanks. (Methods Materials and methods section, page 5, lines 127). The revised paragraph now reads as follows: “Methods Materials and methods Participants and study design … Survey data from 2011-2018 were combined by identity document‌, resulting in a longitudinal survey of 13,263 data. There were 489 data with positive cognitive impairment at baseline. …” Comment 4: In lines 172-182, phrases like ‘such as’, ‘including…’ are used, and this might indicate there are more variables listed below, so rephrase it (unless there are more variables not mentioned in that paragraph) Response: Thanks for your valuable advice. We have deleted those (‘such as’, ‘including…’) in the manuscript. (Methods Materials and methods section, page 7, lines 175-184). The revised paragraph now reads as follows: “Methods Materials and methods Covariates … According to previous articles [27, 34]�covariates are primarily categorized into the following groups: 1) Personal variables: age, gender (male, female), education level (high school or below, undergraduate or higher), and residence (rural, urban, or other); 2) Health status-related variables: body mass index (BMI) are categorized as follows: underweight (<18.5), normal weight (18.5 ≤ BMI <25), overweight (25 ≤ BMI <30), and obese (BMI ≥30); 3) Lifestyle variables, smoking status (current smoker, former smoker, never smoker) and alcohol consumption (current drinker, former drinker, never drinker); 4) Chronic disease conditions: hypertension (no, yes), hyperlipidemia (no, yes), diabetes (no, yes), and lung disease (no, yes).” Reviewer #2: PLOS ONE Ref: PONE-D-25-38651 Title: “Independent and joint associations of volume and intensity of physical activity on cognitive impairment among middle-aged and elderly Chinese adults: a national longitudinal study” In general, the language is good. however, there are some areas for suggested improvement. Response: We thank for your valuable comments and suggestions. We have carefully revised the manuscript to enhance its clarity and facilitate the understanding of readers. Our point-to-point responses are presented in the following. minor edits only: Comment 1: in the abstract: Suggest "....and their combined risk for cognitive impairment", rather than "their combination" Response: We thank the reviewer for this valuable comment. We have revised " their combined " to "their combination". (Abstracts section, page 2, lines 37-38). The revised paragraph now reads as follows: “Abstracts Background: The objective of this study was to explore the longitudinal relationship between the volume and intensity of physical activity (PA) and their combined risk for cognitive impairment (CI).” Comment 2: In the introduction, a suggestion to define cognitive impairment in the context of the study from the outset. Define what exactly this study is examining- cognitive impairment or dementia (which is a major neurocognitive disorder) cognitive impairment should ideally be delineated in terms of mild, moderate or severe, which dementia is an example of. NB in line 87 the study appears to examine neurodegenerative disorders. Response: We sincerely thank the reviewer for the valuable suggestion. We have added define cognitive impairment in the context of the study in the introduction. In addition, we have deleted the study appears to examine neurodegenerative disorders in line 87. (Introduction section, page 3, lines 65-67). The revised paragraph now reads as follows: “Introduction Cognitive impairment (CI) refers to a significant decline or dysfunction in memory, learning, attention, language, executive function, and other cognitive domains[1], …” The relevant certificate involved is listed as follows: 1. Petersen, R.C., et al., Mild cognitive impairment: ten years later. Arch Neurol, 2009. 66(12): p. 1447-55. Comment 3: line 79, " The World Health Organization (WHO) recommends 150-300 minutes of moderate-intensity physical activity per week, 75-150 minutes of vigorous-intensity physical activity, or some equivalent combination of moderate intensity and vigorous-intensity aerobic physical activity per week. " suggest the authors indicate what exactly for? to maintain a good physique/remain healthy/ avoid dementia, prevent various illnesses? Response: We thank the reviewer for this insightful suggestion. We have revised "The World Health Organization (WHO) recommends 150-300 minutes of moderate-intensity physical activity per week, 75-150 minutes of vigorous-intensity physical activity, or some equivalent combination of moderate intensity and vigorous-intensity aerobic physical activity per week." to "The World Health Organization (WHO) recommends 150-300 minutes of moderate-intensity physical activity per week, 75-150 minutes of vigorous-intensity physical activity, or some equivalent combination of moderate-intensity and vigorous-intensity aerobic physical activity per week to gain health benefits such as improvements of cognitive health".( Introduction section, page 3, lines 82-85). Comment 4: line 106-108: check grammar. suggest "utilized" or motivate for the study adequately. Response: We sincerely thank for the valuable comment. We have revised to "utilized". (Introduction section, page 4, lines 108). The revised paragraph now reads as follows: “Introduction …Based on this, this study utilized a nationally representative sample from the China Health and Retirement Longitudinal Study (CHARLS) to explore the longitudinal relationship between volume and intensity of PA and their combined risk for CI.” Comment 5: line 126-129: suggest full stop after the word "baseline" in "There were 489 data with positive cognitive impairment at 127 baseline. then: "Twenty five with missing data in PA and cognitive impairment data at baseline were excluded, and 1487 with missing data in longitudinal cognitive impairment data were excluded, leaving 11262 data." Response: We sincerely thank for the valuable comment. We have revised in the manuscript. (Methods Materials and methods section, page 5, lines 128-129). The revised paragraph now reads as follows: “Methods Materials and methods Participants and study design …Survey data from 2011-2018 were combined by identity document‌, resulting in a longitudinal survey of 13,263 data. There were 489 data with positive cognitive impairment at baseline. Twenty five with missing data in PA and cognitive impairment data at baseline were excluded, and 1487 with missing data in longitudinal cognitive impairment data were excluded, leaving 11262 data.” Comment 7: line 145, revise sentence to indicate what is "calculated as follows"? the MET score? if so, state this clearly. Response: We sincerely thank for the valuable comment. We have revised "calculated as follows" to " The MET score was calculated as follows " in the manuscript. (Methods Materials and methods section, page 6, lines 147-148). The revised paragraph now reads as follows: “Methods Materials and methods Physical activity … The MET score was calculated as follows: PAV = 8.0 × duration of vigorous-intensity physical activity (VPA) per week + 4.0 × duration of Moderate-intensity physical activity (MPA) per week + 3.3 × duration of light-intensity physical activity (LPA) per week [28]. …” Comment 8: line 149, suggest "therefore, we elected to divide the results according into two main categories...." Response: We sincerely thank for the valuable comment. We have revised to "therefore, we elected to divide the results according into two main categories...." in the manuscript. (Methods Materials and methods section, page 6, lines 152-153). The revised paragraph now reads as follows: “Methods Materials and methods Physical activity … According to IPAQ, Insufficient PA is defined as the PAV less than 600 MET minutes/week [29], therefore, we elected to divide the results according into two main categories (0-599 and ≥600) and seven subcategories in terms of MET minutes/week (0-599, 600-1199, 1200 -1799, 1800-2999, 3000-5999, 6000-8999 and ≥9000). …” Comment 9: line 156: suggest "domains" or "functions" not "abilities" Response: We sincerely thank for the valuable comment. We have revised to " functions." in the manuscript. (Methods Materials and methods section, page 6, lines 159). The revised paragraph now reads as follows: “Methods Materials and methods Cognitive impairment … Cognitive impairment was assessed based Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0339124.r002
2 Dec 2025 Decision Letter - Demitri Constantinou, Editor Independent and joint associations of volume and intensity of physical activity on cognitive impairment among middle-aged and elderly Chinese adults: a national longitudinal study PONE-D-25-38651R1 Dear Dr. Sun, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Demitri Constantinou, MD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0339124.r003
Formally Accepted
Acceptance Letter - Demitri Constantinou, Editor PONE-D-25-38651R1 PLOS One Dear Dr. Sun, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Demitri Constantinou Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0339124.r004

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