The effect of physical activity on brain structure and cognitive function in the population-based cohort of LIFE-Adult-Study

Reviewer #1 (Public review):

Summary:

The authors investigated the relationship between physical activity (PA) and both structural (MRI) and cognitive brain health in the LIFE-Adult Study, with total baseline recruitment of 2576. Hippocampal volume, an MRI-derived BrainAGE marker, and scores from the Trail Making Test were used as outcomes, with the majority of participants measured at baseline and subsets also measured in a follow-up session. The key findings were a lack of direct association between PA and outcomes, but longitudinal evidence for a higher BrainAge at baseline leading to lower physical capacity at follow-up. This supports a reverse-causation hypothesis in contrast to the prevailing understanding of the positive effects of physical activity on brain health.

Strengths:

The Life-Adult study is a rich and carefully acquired dataset, with multiple follow-up time points. The statistical analyses were conducted carefully with appropriate control for confounds and multiple testing. The study design enables an important assessment for reverse causality. The authors are scrupulous in their consideration of a number of factors that could potentially bias their results, performing an age-stratified analysis, and emphasising discrepancies in PA measurements (specifically, age-reporting bias) across the dataset and other limitations.

Weaknesses:

This is an observational study with inconsistent measures of physical activity. Previous studies have used physical activity interventions, and might be more strongly weighted when considering evidence for these effects (specific confounders involved in interventions notwithstanding).

The model identifying potential reverse causality is relatively limited - it seems possible/likely that brainAge could reflect more general health status, which would expand the potential range of factors underlying this observation.

The important quantitative actigraphy subset is small (n=227), as are the longitudinal subsets. Along with the discrepancy of physical activity/capacity at baseline and follow-up, and other complexities of the dataset, it is difficult to make firm conclusions. The authors point out that the actigraphy subset was quite inactive.

Reviewer #2 (Public review):

Summary:

This population-based cohort study found no evidence that physical activity, whether self-reported or objectively measured, positively influenced brain structure (hippocampal volume or BrainAGE) or cognitive function (Trail Making Test scores). Notably, longitudinal analyses suggested the opposite temporal relationship: a higher BrainAGE at baseline predicted higher physical capacity at follow-up, more in line with reverse causation rather than a neuroprotective effect of physical activity.

Strengths:

The study's statistical approach is thorough and well-documented, and the inclusion of two measurements of physical activity (self-report questionnaire and objective accelerometer data) is a strength. The longitudinal aspect also represents a strength.

Weaknesses:

Several aspects of the measurement timing warrant consideration. Physical activity was assessed over 7-day periods, creating a potential mismatch with (commonly less dynamic) brain outcomes examined (hippocampal volume, BrainAGE), which may reflect cumulative exposures over longer timescales. Additionally, the asynchronous measurement protocol (cognitive testing preceding accelerometry, and the MRI occurring weeks after baseline visits) may introduce time lags that attenuate associations. The observed null associations may be influenced by timing misalignment rather than reflecting the absence of consistent effects of physical activity on brain health and cognition.

Other measurement characteristics also warrant consideration when interpreting the null findings. Physical activity was assessed using short-form self-report questionnaires and averaged accelerometer MET/day values, both of which have limited reliability. Additionally, the modest accelerometer subsample size and low/insufficient variation in activity levels observed in this cohort increase the likelihood of missing effects. These factors collectively raise the possibility that true physical activity-brain health associations may have been obscured.

The study's conclusions regarding brain health, structure, and cognitive functioning are broad despite the scope of the selection of outcomes examined. The analyses focus on hippocampal volume, BrainAGE (a global aging metric), and Trail Making Test performance (processing speed and executive function), while omitting other important neuroimaging markers such as cortical thickness, functional connectivity, or white matter microstructure. The null findings presented here cannot exclude positive effects of physical activity on broader constructs of brain health or cognitive functioning.

While the authors appropriately note the use of different physical activity instruments across time points (IPAQ at baseline, VSAQ at follow-up) in the limitations section, the discussion should more explicitly address the interpretive challenges this creates. The observed association between higher baseline brain age gap and lower follow-up physical activity may reflect: (1) a true temporal relationship, (2) an artifact of switching from behavior-focused (IPAQ) to capacity-focused (VSAQ) measurement, or (3) some combination of both. This ambiguity substantially limits causal inference.