Open Access

A systematic review of the evidence for Canada's Physical Activity Guidelines for Adults

  • Darren ER Warburton1, 2Email author,
  • Sarah Charlesworth1, 2,
  • Adam Ivey1, 2,
  • Lindsay Nettlefold1, 2 and
  • Shannon SD Bredin3
International Journal of Behavioral Nutrition and Physical Activity20107:39

DOI: 10.1186/1479-5868-7-39

Received: 24 July 2009

Accepted: 11 May 2010

Published: 11 May 2010

Abstract

This systematic review examines critically the scientific basis for Canada's Physical Activity Guide for Healthy Active Living for adults. Particular reference is given to the dose-response relationship between physical activity and premature all-cause mortality and seven chronic diseases (cardiovascular disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes (diabetes mellitus) and osteoporosis). The strength of the relationship between physical activity and specific health outcomes is evaluated critically. Literature was obtained through searching electronic databases (e.g., MEDLINE, EMBASE), cross-referencing, and through the authors' knowledge of the area. For inclusion in our systematic review articles must have at least 3 levels of physical activity and the concomitant risk for each chronic disease. The quality of included studies was appraised using a modified Downs and Black tool. Through this search we identified a total of 254 articles that met the eligibility criteria related to premature all-cause mortality (N = 70), cardiovascular disease (N = 49), stroke (N = 25), hypertension (N = 12), colon cancer (N = 33), breast cancer (N = 43), type 2 diabetes (N = 20), and osteoporosis (N = 2). Overall, the current literature supports clearly the dose-response relationship between physical activity and the seven chronic conditions identified. Moreover, higher levels of physical activity reduce the risk for premature all-cause mortality. The current Canadian guidelines appear to be appropriate to reduce the risk for the seven chronic conditions identified above and all-cause mortality.

Introduction

There is considerable literature supporting the importance of habitual physical activity in the primary and secondary prevention of varied chronic conditions [116]. Routine physical activity is thought to be of benefit for over 25 chronic conditions [17]. Seven chronic diseases in particular have been associated with a physically inactive lifestyle including coronary artery disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes (diabetes mellitus) and osteoporosis [1820].

Canada has played a leading role in the development of physical activity guidelines for individuals across the lifespan. This includes the development (in 1998) of "Canada's Physical Activity Guide to Healthy Active Living" for adults between the ages of 20 and 55 yr [21], which was followed by "Canada's Physical Activity Guide to Healthy Active Living for Older Adults" [22], and "Canada's Physical Activity Guide to Healthy Active Living for Children and Youth" [23]. The adult guidelines (which are now approximately 10 years old) state generally that 20-55 yr adults should accumulate 60 min of daily physical activity or 30 min of moderate to vigorous exercise on at least 4 days a week [18, 19].

We reported recently that Canada's adult guidelines were consistent with other international guidelines and were supported by a compelling body of literature [18, 19]. We revealed strong evidence that routine physical activity was effective in the primary prevention of cardiovascular disease, stroke, hypertension, breast cancer, colon cancer, type 2 diabetes and osteoporosis. Moreover, physical activity appears to play an important role in the prevention of obesity and obesity-related co-morbidities. However, implicit in the adult guidelines is the belief that there is a dose-response relationship between physical activity and the associated health benefits. Moreover, a central belief in these guidelines and most international physical activity guidelines is that the dose-response relationship is curvilinear with the greatest health benefits seen in physically inactive individuals who become "more physically active." In fact, a consistent pattern (shown in Figure 1) has been hypothesized, wherein there are marked changes in health status with relatively minor increments in physical activity/fitness in individuals that are the least active/fit. Generally, the health benefits have been thought to level off at the upper end of the physical activity/fitness continuum (Figure 1). However, recent work (such as that provided by Gledhill and Jamnik in the Canadian Physical Activity and Lifestyle Approach) has speculated that there are likely multiple dose-response curves for various endpoints [24].
https://static-content.springer.com/image/art%3A10.1186%2F1479-5868-7-39/MediaObjects/12966_2009_Article_345_Fig1_HTML.jpg
Figure 1

Theoretical relationship between the risk for chronic disease and physical activity/fitness.

The primary purpose of this systematic review was to examine critically the current literature to determine whether or not a dose-response relationship exists between habitual physical activity and chronic disease. In particular, we sought to determine whether the key messaging "Every little bit counts, but more is even better - everyone can do it!" of the adult physical activity guidelines is supported by a strong body of evidence.

Due to the breadth of literature, we have chosen to focus on the relationship between physical activity and all-cause mortality, and the seven chronic conditions that are thought to be reduced greatly with habitual physical activity (i.e., cardiovascular disease (excluding stroke), stroke, hypertension, colon cancer, breast cancer, type 2 diabetes and osteoporosis) (see Table 1). Owing to the nature of the physical activity guidelines, the emphasis of this paper was on primary prevention, despite the clear evidence that routine physical activity is also an effective secondary preventative strategy against many chronic conditions [16, 18, 19]. Accordingly, our primary objectives were to examine the evidence for a dose-response relationship between: 1) physical activity and all-cause mortality, and 2) physical activity and incidence of the following chronic conditions (cardiovascular disease (except stroke), stroke, hypertension, type 2 diabetes, colon cancer, breast cancer, and osteoporosis.
Table 1

Relative risks (RR) and population attributable risks (PAR%) for physical inactivity in Canada, Australia, and the USA.

 

Canada

Australia

USA

Disease

RR

PAR%

RR

PAR%

RR

PAR%

CHD

1.45

19.4

1.5

18

2.0

22

Stroke

1.60

24.3

2.0

16

na

Na

Hypertension

1.30

13.8

na

na

1.5

12

Colon Cancer

1.41

18.0

1.5

19

2.0

22

Breast Cancer

1.31

14.2

1.1

9

1.2

5

Type 2 Diabetes

1.50

21.1

1.3

13

1.5

12

Osteoporosis

1.59

24.0

1.4*

18*

2.0

18*

Source: Canadian Data [20]; Australian Data [161]; US Data: [162]. *Evaluated the incidence of falls/fractures.

Methods

Criteria for considering studies for this review

Our research team utilized a rigorous, systematic, and evidence-based approach to examine critically the levels of evidence on physical activity and the risk for premature mortality and chronic disease. Any studies that evaluated the relationship between at least three different levels of physical activity and mortality or incidence of chronic disease were eligible for inclusion. Therefore, excluded studies included those that examined only the most active versus least active populations (e.g., sedentary/inactive vs. physically active). Any form of physical activity/exercise measurement (e.g., self-report, pedometer, accelerometer, maximal aerobic power (VO2 max)) was eligible for inclusion. The key outcomes were mortality and incidence of chronic disease. Only published, English language studies examining adults (e.g., 19-65 yr) were included. Participants must have previously been healthy (asymptomatic) adults without established chronic disease. There was no restriction according to study design.

To examine the relative risk reductions associated with physical activity, we calculated the mean and median risk reductions across studies focusing on the highest level versus the lowest level of physical activity/fitness. For each study we also determined whether or not a dose-response relationship was present (i.e., reflecting a progressive decrease in the risk with increasing physical activity/fitness levels).

Search strategy

Literature searches were conducted in the following electronic bibliographical databases:

  • MEDLINE (1950-March 2008, OVID Interface);

  • EMBASE (1980- March 2008, OVID Interface),

  • CINAHL (1982- March 2008, OVID Interface);

  • PsycINFO (1840- March 2008, Scholars Portal Interface);

  • Cochrane Library (-March 2008),

  • SPORTDiscus (-March 2008).

The Medical Subject Headings (MeSH) were kept broad. See tables 2, 3, 4, 5, 6, 7, 8 and 9 for the complete search strategy and keywords used. The electronic search strategies were created and carried out by researchers experienced with systematic reviews of the literature (DW and LN). The citations and applicable electronic versions of the article (where available) were downloaded to an online research management system (RefWorks, Bethesda, Maryland, USA).
Table 2

Results of the MEDLINE literature search regarding all-cause mortality.

#

Searches (28 Feb 2008)

Results

1

exp Physical Fitness/

15236

2

Motor Activity/

49721

3

exp Physical Endurance/

15383

4

exp Exercise/

57742

5

exp Exertion/

88903

6

exp Sports/

71887

7

exp exercise therapy/

17231

8

exp exercise tolerance/

4192

9

exp health behaviour/

59409

10

leisure time physical activity.mp

996

11

occupational physical activity.mp

190

12

exp Pliability/

2279

13

exp Muscle Strength/

5717

14

musc$ power.mp

965

15

exp Back/

12821

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291635

17

dose-response.mp

321066

18

intensity.mp

142881

19

volume.mp

298471

20

exp Energy Metabolism/

206808

21

exp oxygen consumption/

83352

22

exp time factors/

763712

23

17 or 18 or 19 or 20 or 21 or 22

1651633

24

16 and 23

67698

25

exp Mortality/

190058

26

all cause mortality.mp

4618

27

25 or 26

192720

28

24 and 27

421

29

limit 28 to (english and humans and "all adult (19 plus years)

279

Table 3

Results of the MEDLINE literature search regarding cardiovascular disease.

Search #

Searches (3 Mar 2008)

Results

1

exp Physical Fitness/

15244

2

Motor Activity/

49751

3

exp Physical Endurance/

15408

4

exp Exercise/

57806

5

exp Exertion/

88967

6

exp Sports/

71931

7

exp exercise therapy/

17243

8

exp exercise tolerance/

4205

9

exp health behaviour/

59467

10

leisure time physical activity.mp

998

11

occupational physical activity.mp

191

12

exp Pliability/

2289

13

exp Muscle Strength/

5731

14

musc$ power.mp

965

15

exp Back/

12822

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291817

17

dose-response.mp

321198

18

intensity.mp

142955

19

volume.mp

298620

20

exp Energy Metabolism/

206886

21

exp oxygen consumption/

83387

22

exp time factors/

764091

23

17 or 18 or 19 or 20 or 21 or 22

1652372

24

16 and 23

67760

25

exp Cardiovascular Diseases/

1411730

26

exp Heart diseases/

675083

27

exp Myocardial infarction/

116070

28

exp Death, Sudden Cardiac/

6772

29

exp Coronary Artery Disease/

18137

30

exp Coronary Disease/

144236

31

exp Vascular Diseases

1018275

32

25 or 26 or 27 or 28 or 29 or 30 or 31

1411730

33

24 and 32

9603

34

limit 33 to (english language and humans and "all adult (19 plus years)")

5544

Table 4

Results of the MEDLINE literature search regarding stroke.

Search #

Searches (29 Feb 2008)

Results

1

exp Physical Fitness/

15241

2

Motor Activity/

49744

3

exp Physical Endurance/

15387

4

exp Exercise/

57764

5

exp Exertion/

88921

6

exp Sports/

71907

7

exp exercise therapy/

17237

8

exp exercise tolerance/

4196

9

exp health behaviour/

59430

10

leisure time physical activity.mp

996

11

occupational physical activity.mp

190

12

exp Pliability/

2288

13

exp Muscle Strength/

5720

14

musc$ power.mp

965

15

exp Back/

12821

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291718

17

dose-response.mp

321133

18

intensity.mp

142919

19

volume.mp

298526

20

exp Energy Metabolism/

206837

21

exp oxygen consumption/

83359

22

exp time factors/

763871

23

17 or 18 or 19 or 20 or 21 or 22

1651958

24

16 and 23

67720

25

exp Stroke/

45243

26

exp Cerebrovascular Disorders/

196243

27

exp Brain Ischemia/

58943

28

exp Brain Infarction/ or exp Cerebral Infarction

21357

29

exp Infarction, Middle Cerebral Artery/ or exp Intracranial Aneurysm/ or exp Subarachnoid

46725

30

Hemorrhage/ or exp Cerebral Hemorrhage/exp Ischemic Attack, Transient/

14753

31

25 or 26 or 27 or 28 or 29 or 30

196243

32

24 and 31

692

33

limit 32 to (english language and humans and "all adult (19 plus years)")

291

Table 5

Results of the MEDLINE literature search regarding hypertension.

Search #

Searches (3 Mar 2008)

Results

1

exp Physical Fitness/

15244

2

Motor Activity/

49751

3

exp Physical Endurance/

15408

4

exp Exercise/

57806

5

exp Exertion/

88967

6

exp Sports/

71931

7

exp exercise therapy/

17243

8

exp exercise tolerance/

4205

9

exp health behaviour/

59467

10

leisure time physical activity.mp

998

11

occupational physical activity.mp

191

12

exp Pliability/

2289

13

exp Muscle Strength/

5731

14

musc$ power.mp

965

15

exp Back/

12822

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291817

17

dose-response.mp

3211987

18

intensity.mp

142955

19

volume.mp

298620

20

exp Energy Metabolism/

206886

21

exp oxygen consumption/

83387

22

exp time factors/

764091

23

17 or 18 or 19 or 20 or 21 or 22

1652372

24

exp Hypertension/

168466

25

exp Blood Pressure/

205571

26

exp Blood Pressure Determination/ or exp Blood Pressure Monitoring, Ambulatory/ or exp Blood

18244

27

Pressure Monitors/24 or 25 or 26

336025

28

16 and 23 and 27

5647

29

limit 28 to (english language and humans and "all adult (19 plus years)")

3642

Table 6

Results of the MEDLINE literature search regarding colon cancer.

Search #

Searches (3 Mar 2008)

Results

1

exp Physical Fitness/

15244

2

Motor Activity/

49751

3

exp Physical Endurance/

15408

4

exp Exercise/

57806

5

exp Exertion/

88967

6

exp Sports/

71931

7

exp exercise therapy/

17243

8

exp exercise tolerance/

4205

9

exp health behaviour/

59467

10

leisure time physical activity.mp

998

11

occupational physical activity.mp

191

12

exp Pliability/

2289

13

exp Muscle Strength/

5731

14

musc$ power.mp

965

15

exp Back/

12822

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291817

17

dose-response.mp

321198

18

intensity.mp

142955

19

volume.mp

298620

20

exp Energy Metabolism/

206886

21

exp oxygen consumption/

83387

22

exp time factors/

764091

23

17 or 18 or 19 or 20 or 21 or 22

1652372

24

exp Colonic Neoplams/

51780

25

exp Rectal Neoplasms/

28011

26

exp Colorectal Neoplasms/

99982

27

exp Colorectal Neoplasms/, Hereditary Nonpolyposis/ or exp Intestinal Neoplasms.

117563

28

24 or 25 or 26 or 27

117563

29

16 and 23 and 28

108

30

limit 29 to (53nglish language and humans and "all adult (19 plus years)")

77

Table 7

Results of the MEDLINE literature search regarding breast cancer.

Search #

Searches (28 Feb 2008)

Results

1

exp Physical Fitness/

15236

2

Motor Activity/

49721

3

exp Physical Endurance/

15383

4

exp Exercise/

57742

5

exp Exertion/

88903

6

exp Sports/

71887

7

exp exercise therapy/

17231

8

exp exercise tolerance/

4192

9

exp health behaviour/

59409

10

leisure time physical activity.mp

996

11

occupational physical activity.mp

190

12

exp Pliability/

2279

13

exp Muscle Strength/

5717

14

musc$ power.mp

965

15

exp Back/

12821

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291635

17

dose-response.mp

321066

18

intensity.mp

142881

19

volume.mp

298471

20

exp Energy Metabolism/

206808

21

exp oxygen consumption/

83352

22

exp time factors/

763712

23

17 or 18 or 19 or 20 or 21 or 22

1651633

24

exp Breast Neoplasms/

149817

25

16 and 23 and 24

296

26

limit 25 to (54 nglish language and humans and "all adult (19 plus years)"

216

Table 8

Results of the MEDLINE literature search regarding type 2 diabetes.

Search #

Searches (29 Feb 2008)

Results

1

exp Physical Fitness/

15241

2

Motor Activity/

49744

3

exp Physical Endurance/

15387

4

exp Exercise/

57764

5

exp Exertion/

88921

6

exp Sports/

71907

7

exp exercise therapy/

17237

8

exp exercise tolerance/

4196

9

exp health behaviour/

59430

10

leisure time physical activity.mp

996

11

occupational physical activity.mp

190

12

exp Pliability/

2288

13

exp Muscle Strength/

5720

14

musc$ power.mp

965

15

exp Back/

12821

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291718

17

dose-response.mp

321133

18

intensity.mp

142919

19

volume.mp

298526

20

exp Energy Metabolism/

206837

21

exp oxygen consumption/

83359

22

exp time factors/

763871

23

17 or 18 or 19 or 20 or 21 or 22

1651958

24

16 and 23

67720

25

exp Blood Glucose/or exp Diabetes Mellitus, Type 2/

132583

26

exp Hyperglycemia/

16214

27

exp Glucose Intolerance/ or exp Glucose Tolerance Test/

24986

28

exp Hyperinsulinism/

30490

29

25 or 26 or 27 or 28

165157

30

29 and 24

3006

31

Limit 30 to (english language and humans and "all adult (19 plus years)")

1985

Table 9

Results of the MEDLINE literature search regarding osteoporosis.

Search #

Searches (29 feb 2008)

Results

1

exp Physical Fitness/

15241

2

Motor Activity/

49744

3

exp Physical Endurance/

15387

4

exp Exercise/

57764

5

exp Exertion/

88921

6

exp Sports/

71907

7

exp exercise therapy/

17237

8

exp exercise tolerance/

4196

9

exp health behaviour/

59430

10

leisure time physical activity.mp

996

11

occupational physical activity.mp

190

12

exp Pliability/

2288

13

exp Muscle Strength/

5720

14

musc$ power.mp

965

15

exp Back/

12821

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

291718

17

dose-response.mp

321133

18

intensity.mp

142919

19

volume.mp

298526

20

exp Energy Metabolism/

206837

21

exp oxygen consumption/

83359

22

exp time factors/

763871

23

17 or 18 or 19 or 20 or 21 or 22

1651958

24

exp Osteoporosis, Postmenopausal/ or exp Osteoporosis/

31532

25

exp Fractures, Bone/ or exp Bone Density/

125269

26

exp Bone Diseases/ or exp Bone Diseases, Metabolic/

308084

27

exp "Bone and bones"/

369634

28

exp Tensile Strength/

12050

29

exp Compressive Strength

2838

30

24 or 25 or 26 or 27 or 28 or 29

642158

31

16 and 23 and 30

2138

32

limit 31 to (english language and humans and "all adult (19 plus years)")

1193

Screening

Two reviewers (LN and SC) screened independently the title and abstract of the citations to identify potential articles for inclusion. Duplicate citations were removed. The reviewers were not blinded to the authors or journals. Biographies of key studies and reviews in the field were also cross-referenced for further articles. For those articles that appeared relevant, the full text was obtained and data was extracted using a common template. In cases of disagreement, discussion with a third reviewer (DW) was used to achieve consensus. Full (100%) consensus was achieved. All studies that were excluded during the citation and full-article screening processes were recorded along with the reasons for exclusion.

Data Extraction

Two reviewers (LN and SC) completed standardized data extraction forms, which were verified by two other reviewers (DW and SB). We extracted information regarding the study design, the country where the study was conducted, the participant characteristics, the sample size, the objectives of the study, the methodologies employed, the major outcomes (i.e., mortality, incidence of chronic disease, physical activity levels/classifications), and the comments and conclusions made based on the findings of the study. The reviewers were not blinded to the journal or the author names when extracting information from the articles.

Level of Evidence

The approach used to establish the level and grade of evidence was consistent with that used during creation of the "Canadian clinical practice guidelines on the management and prevention of obesity in adults and children" [25]. The level of evidence provides information regarding the strength of the evidence in favour of physical activity/exercise in the primary prevention of premature mortality and the seven chronic diseases of primary interest. This evaluation process is based on a pre-defined and objective criteria (see Table 10).
Table 10

The levels and grade of evidence scaling criteria applied to the articles.

Level of Evidence

Criteria

Level 1

   Randomized control trials without important limitations

Level 2

   • Randomized control trials with important limitations

 

   • Observational studies (non-randomized clinical trials or cohort studies) with overwhelming evidence

Level 3

Other observational studies (prospective cohort studies, case-control studies, case series)

Level 4

Inadequate or no data in population of interest

 

Anecdotal evidence or clinical experience

Grade of Evidence

Criteria

Grade A

Strong recommendation (action can apply to most individuals in most circumstances)

 

   • Benefits clearly outweigh risks (or vice-versa)

 

   • Evidence is at Level 1, 2, or 3

Grade B

Weak recommendation (action may differ depending on individual's characteristics or other circumstances)

 

   • Unclear if benefits outweigh risks

 

   • Evidence is at Level 1, 2, or 3

Grade C

Consensus recommendation (alternative actions may be equally reasonable)

 

   • Unclear if benefits outweigh risks

 

   • Evidence is at Level 3 or 4

The grade for each article provides information regarding whether physical activity is effective in the primary prevention of the varied conditions evaluated (Table 10). Where applicable this grade informs the reader about the potential risk of the physical activity. A study that receives the highest grading would indicate that the benefits clearly outweigh the risks and receive a strong recommendation.

Quality Assessment

The quality of each study was also established using the procedures of Gorber et al. [26]. Owing to the fact that only observational study designs were included in our systematic review, we used the Downs and Black [27] scale to assess the quality of non-randomized investigations. Similar to the work of Prince et al. [28] we chose to include the most relevant components of the scoring tool. Therefore, a modified version of the Downs and Black checklist was used with the final checklist consisting of 15 items with a maximum score of 15 points. Higher points reflected a superior quality of investigation.

Results

Physical Inactivity and All-Cause Mortality

A total of 2040 citations were identified during the electronic database search (Figure 2). Of these citations, 288 were identified in MEDLINE, 222 in EMBASE, 496 in Cochrane, and 1034 in the CINAHL/SportDiscus/PsychInfo search. A total of 167 duplicates were found, leaving a total of 1873 unique citations. A total of 1696 articles were excluded after scanning, leaving a total of 177 articles for full review. From these articles 130 were excluded after full review leaving 47 articles for inclusion in the systematic review. An additional 23 articles were added to the review based on the authors' knowledge of the area. The reasons for exclusion included review articles (n = 26), commentary (n = 10), did not report 3 levels of physical activity (n = 24), no objective measure of physical activity (n = 2), report (n = 15), not a formal study (n = 11), not related to all-cause mortality (n = 27), the participants were too young (n = 1), not able to retrieve articles (n = 7), and other (n = 7). Therefore, a total of 70 articles were included in the systematic review of the literature regarding the relationship between physical activity and premature mortality.
https://static-content.springer.com/image/art%3A10.1186%2F1479-5868-7-39/MediaObjects/12966_2009_Article_345_Fig2_HTML.jpg
Figure 2

Results of the Literature Search for All-Cause Mortality.

The majority of the studies included in our systematic review were prospective cohort investigations (Table 11). These studies involved a total of 1,525,377 participants; averaging 21,791 participants per study (range 302-252,925). There were a total of 111,125 reported cases of premature all-cause mortality (ranging per study from 43-10,952). The total length of study follow-up for the prospective cohort studies averaged 11.1 yr (ranging from 0.5-28 yr). The articles were published over a 22 yr period ranging from 1985 to 2007. These studies involved large samples of men and women from regions throughout the world.
Table 11

Studies examining the relationship between physical activity and all-cause mortality.

Publication Country Study Design Quality Score

Objective

Population

Methods

Outcome

Comments and Conclusions

Blair et al 1989 [7]

To study physical fitness (PF) and risk of all-cause mortality in men and women.

• n = 13,344 (10,224 men; 3,120 women)

Baseline and 8 year follow-up

   • 283 deaths

Low levels of PF increase the risk for premature mortality.

  

• Sex: Men and women

 

Adjusted risk ratio (RR), 95% confidence interval (CI)

 

USA

 

• Age: 20->60 years (yr)

PF assessment: Maximal treadmill exercise test.

  

Prospective cohort

 

• Characteristics: Participants were given a preventative Medicine examination including maximal treadmill exercise test

Fitness categorized into quintiles:

Men

 

D & B score = 12

  

Q1 = least fit

   • Q1 = 3.44 (2.05-5.77)

 
   

Q2

   • Q2 = 1.37 (0.76-2.50)

 
   

Q3

   • Q3 = 1.46 (0.81-2.63)

 
   

Q4

   • Q4 = 1.17 (0.63-2.17)

 
   

Q5 = most fit

   • Q5 = 1.00 (referent)

 
    

Women

 
    

   • Q1 = 4.65 (2.22-9.75)

 
    

   • Q2 = 2.42 (1.09-5.37)

 
    

   • Q3 = 1.43 (0.60-3.44)

 
    

   • Q4 = 0.76 (0.27-2.11)

 
    

   • Q5 = 1.00 (referent)

 

Myers et al 2004 [32]

To determine the effects of PF and physical activity (PA) on all-cause mortality.

• n = 6,213

Baseline and mean 5.5 ± 2.0 year follow-Up

   • 1,256 deaths

Being fit or active is associated with >50% reductions in mortality risk.

  

• Sex: Men

   

USA

 

• Age: Mean 59.0 ± 11.2 yr

 

PF Level hazard ratio (HR) (95% CI)

 
  

• Characteristics: Men referred for exercise testing

PF assessment: Treadmill test to measure VO2 peak

   • G1 = 1.00 (referent)

PF predicted mortality more strongly than PA.

Prospective cohort

   

   • G2 = 0.59 (0.52-0.68)

 
    

   • G3 = 0.46 (0.39-0.55)

 
    

   • G4 = 0.28 (0.23-0.34)

Increasing PA (by 1000 kcal/wk or 1 MET) confers a mortality benefit of 20%.

D & B score = 12

  

PA assessment: Self reported PA divided into 4 groups

  
    

PA Level HR (95% CI)

 
   

G1 = Lowest level

   • G1 = 1.00 (referent)

 
   

G2

   • G2 = 0.63 (0.36-1.10)

 
   

G3

   • G3 = 0.42 (0.23-0.78)

 
   

G4 = Highest level

   • G4 = 0.38 (0.19-0.73)

 

Blair et al 1995 [36]

To evaluate the relationship between changes in PF and risk of mortality in men.

• n = 9,777

4.9 year mean follow-up

   • 223 deaths

Men who maintained or increased adequate PF had a reduced risk for all-cause mortality than individuals who were consistently unfit.

  

• Sex: Men

   
  

• Age: 20-82 yr

 

RR (95% CI)

 

USA

 

• Characteristics: Participants were given a preventative medicine examination including maximal treadmill exercise test

PF assessment: Maximal exercise test at baseline and follow-up

   • G1 = 1.00 (referent)

 

Prospective cohort

   

   • G2 = 0.56 (0.41-0.75)

 
    

   • G3 = 0.52 (0.38-0.70)

 
    

   • G4 = 0.33 (0.23-0.47)

 

D & B score = 13

  

Groups based on changes in PF

  
   

G1 = unfit to unfit

  
   

G2 = unfit to fit

  
   

G3 = fit to unfit

  
   

G4 = fit to fit

  

Bijnen et al 1999 [37]

To examine the association of PA at baseline and 5 years

• n = 472

1985 and 1990

   • 118 deaths

Recent levels of PA were more important for mortality risk than PA 5 years previously.

  

• Sex: Men

   
  

• Age: >65 yr

PA assessment: Questionnaire, divided into tertiles: Lowest Middle Highest

Multivariate adjusted RR (95% CI)

 

Netherlands

previously with all- cause mortality risk in a cohort of elderly Dutch men.

• Characteristics: Mostly independently living elders (~95%)

 

PA in 1985: Lowest tertile = 1.00 (referent) Middle tertile

 

Retrospective cohort

 

• Zutphen Elderly Study

 

   • Total activity = 1.25 (0.79- 1.99)

Becoming or remaining sedentary increased the mortality risk.

D & B score = 12

   

   • Walking = 0.97 (0.60-1.57)

 
    

   • Bike = 0.97 (0.59-1.57)

 
    

   • Gardening = 0.66 (0.39-1.10)

 
    

   • Other = 1.08 (0.66-1.78)

 
    

   • Heavy activity = 0.73 (0.45-1.17)

 
    

   • Non heavy activity = 0.89 (0.57-1.40)

 
    

Highest tertile

 
    

   • Total activity = 1.25 (0.73-2.12)

 
    

   • Walking = 0.94 (0.58-1.55)

 
    

   • Bike = 1.07 (0.61-1.88)

 
    

   • Gardening = 0.77 (0.42-1.39)

 
    

   • Other = 1.24 (0.74-2.07)

 
    

   • Heavy activity = 0.76 (0.44-1.32)

 
    

   • Non heavy activity = 0.94 (0.58-1.53)

 
    

PA in 1990:

 
    

Lowest tertile = 1.00 (referent)

 
    

Middle tertile

 
    

   • Total activity = 0.56 (0.35-0.89)

 
    

   • Walking = 0.82 (0.51-1.32)

 
    

   • Bike = 0.49 (0.29-0.82)

 
    

   • Gardening = 1.67 (1.00-2.79)

 
    

   • Other = 0.93 (0.53-1.65)

 
    

   • Heavy activity = 1.19 (0.73-1.92)

 
    

   • Non heavy activity = 0.61 (0.38-0.99)

 
    

Highest tertile

 
    

   • Total activity = 0.44 (0.25-0.80)

 
    

   • Walking = 1.17 (0.70-1.96)

 
    

   • Bike = 0.43 (0.23-0.80)

 
    

   • Gardening = 1.03 (0.55-1.94)

 
    

   • Other = 0.74 (0.44-1.23)

 
    

   • Heavy activity = 0.72 (0.40-1.31)

 
    

   • Non heavy activity = 0.65 (0.40-1.05)

 

Gregg et al 2003 [39]

To examine the relationship of changes in PA and mortality among older women.

• n = 9,518

Baseline (1986-1988) and median 10.6 year follow-up (1992-1994)

   • 2,218 deaths

Increasing and maintaining PA levels could lengthen life for older women but appears to provide less benefit for women aged at least 75 years and those with poor health status.

  

• Sex: Women

PA Assessment: Questionnaire, divided into quintiles of PA (kcal/wk)

  
  

• Age: ≥ 65 yr

 

Multivariate adjusted HRR

 

USA

 

• Characteristics: White community dwelling participants from 4 US research centres

 

(95% CI): Quintiles of total

 
   

Q1= <163

PA

 

Prospective cohort

  

Q2 = 163-503

   • Q1 = 1.00 (referent)

 
   

Q3 = 504-1045

   • Q2 = 0.73 (0.64-0.82)

 
   

Q4 = 1046-1906

   • Q3 = 0.77 (0.68-0.87)

 

D & B score = 13

  

Q5 = ≥ 1907

   • Q4 = 0.62 (0.54-0.71)

 
    

   • Q5 = 0.68 (0.59-0.78)

 
    

Walking HRR (95% CI)

 
    

   • Q1 = 1.00 (referent)

 
   

Quintiles of walking(kcal/wk)

   • Q2 = 0.91 (0.81-1.02)

 
   

Q1 = <70

   • Q3 = 0.78 (0.68-0.88)

 
   

Q2 = 70-186

   • Q4 = 0.71 (0.63-0.82)

 
   

Q3 = 187-419

   • Q5 = 0.71 (0.62-0.82)

 
   

Q4 = 420-897

  
   

Q5 = 898

  
    

Multivariate adjusted HRR (95% CI)

 
    

Change in activity level: Sedentary at baseline

 
    

   • Staying sedentary = 1.00 (referent)

 
    

   • Became active = 0.52 (0.40-0.69)

 
    

Mod / high active at baseline

 
    

   • Became sedentary = 0.92 (0.77-1.09)

 
    

   • Stayed active = 0.68 (0.56-0.82)

 

Wannamethee et al 1998 [40]

To study the relationship between heart rate, PA and all- cause mortality.

• n = 5,934

Baseline (1978-1980) and 12-14 year follow-up

   • 219 deaths

Maintaining or taking up light or moderate PA reduces mortality in older men.

  

• Sex: Men

   
  

• Age: Mean 63 yr

 

Multivariate adjusted RR (95% CI),

 

UK

 

• Characteristics: Healthy, sedentary(4,311 were considered "healthy" in 1992)

PA assessment: Questionnaire, split into groups

PA

 

Prospective cohort

 

• The British Regional Heart Study

 

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.61 (0.43-0.86)

 
    

   • G3 = 0.50 (0.31-0.79)

 

D & B score = 12

  

PA score

   • G4 = 0.65 (0.45-0.94)

 
   

G1 =

  
   

Inactive/occasional

Regular walking

 
   

G2 = Light

   • G1 = 1.00 (referent)

 
   

G3 = Moderate

   • G2 = 1.15 (0.73-1.79)

 
   

G4 = Moderately

   • G3 = 1.06 (0.75-1.50)

 
   

vigorous/Vigorous

   • G4 = 0.97 (0.65-1.46)

 
   

Regular walking (min/d)

   • G5 = 0.62 (0.37-1.05)

 
   

G1 = 0

Recreational activity

 
   

G2 = <20

   • G1 = 1.00 (referent)

 
   

G3 = 21-40

   • G2 = 0.95 (0.43-1.07)

 
   

G4 = 41-60

   • G3 = 0.68 (0.43-1.07)

 
   

G5 = ≥ 60

   • G4 = 0.34 (0.35-1.00)

 
   

Recreational activity, 4 groups

Sporting activity

 
   

G1 = Inactive/fairly Inactive

   • G1 = 1.00 (referent)

 
   

G2 = Average 4 hr/weekend

   • G2 = 0.50 (0.25-1.03)

 
   

G3 = Fairly active >4 h/weekend

   • G3 = 0.88 (0.64-1.23)

 
   

G4 = Very active

  
   

Sporting activity, 3 Groups

  
   

G1 = None

  
   

G2 = Occasional

  
   

G3 = >1 time/month

  

Paffenbarger et al 1986 [63]

To examine the PA and life-style characteristics of Harvard alumni for the relationship with all-cause mortality.

• n = 16,936

12-16 year follow-up (1962 to 1978)

   • 1,413 deaths

The findings suggest a protective effect of exercise against all-cause mortality.

  

• Sex: Men

 

Age adjusted RR (95% CI):

 
  

• Age: 35-74

   

USA

 

• Characteristics: Harvard alumni

Records of freshman year physical examinations and records of intercollegiate sport

Those who walked

 

Prospective cohort

   

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.85

 
    

   • G3 = 0.79

 

D & B score = 14

   

Trend p = 0.0009

 
   

PA assessment: Mailed questionnaires surveying post college

Physical Activity Index (95% CI):

 
   

PA

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.78

 
    

   • G3 = 0.73

 
    

   • G4 = 0.63

 
   

Exercise reported: Walking (miles/wk) 3

   • G5 = 0.62

 
   

groups

   • G6 = 0.52

 
   

G1 = <3

   • G7 = 0.46

 
   

G2 = 3-8

   • G8 = 0.62

 
   

G3 = ≥ 9

  
    

Trend p = <0.0001

 
   

PA index (kcal/wk) 3 groups:

  
   

G1 = <500

  
   

G2 = 500-999

  
   

G3 = 1000-1499

  
   

G4 = 1500-1999

  
   

G5 = 2000-2499

  
   

G6 = 2500-2999

  
   

G7 = 3000-3499

  
   

G8 = >3500

  
   

Cox proportional hazard models

  

Schnohr et al 2007 [64]

To determine the impact of walking duration and intensity on all-cause mortality.

• n = 7,308 (3,204 male; 4,104 female)

Baseline and an average of 12 year

   • 1,391 deaths

The findings indicate that the relative intensity and not duration of walking is the most important in relation to all-cause mortality.

Denmark

 

• Sex: Male and female

follow-up

Multivariate adjusted HR (95% CI):

 
  

• Age: 20-93 yr

PA assessment: Questionnaire, 4 durations and 3 intensities

  

Prospective cohort

 

• Characteristics: Participants with no history of CHD, stroke or cancer and who had no difficulty in walking

 

Men

 

D & B score = 12

 

• The Copenhagen City Heart Study

 

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.38 (0.25-0.58)

 
    

   • G3 = 0.38 (0.18-0.79)

 
   

Duration (hours/day)

   • G4 = 0.69 (0.44-1.07)

 
   

1 = <0.5

   • G5 = 0.37 (0.26-0.54)

 
   

2 = 0.5-1

   • G6 = 0.33 (0.18-0.61)

 
   

3 = 1-2

   • G7 = 0.78 (0.50-1.23)

 
   

4 = >2

   • G8 = 0.41 (0.29-0.59)

 
    

   • G9 = 0.33 (0.20-0.54)

 
   

Intensity

   • G10 = 0.43 (0.22-0.82)

 
   

Slow intensity (SI)

   • G11 = 0.42 (0.29-0.60)

 
   

Average intensity (AI)

   • G12 = 0.28 (0.16-0.48)

 
   

Fast intensity (FI)

  
    

Women

 
   

12 groups

   • G1 = 1.00 (referent)

 
   

G1 = 1 and SI

   • G2 = 0.82 (0.52-1.29)

 
   

G2 = 1 and AI

   • G3 = 0.78 (0.27-2.21)

 
   

G3 = 1 and FI

   • G4 = 1.22 (0.82-1.81)

 
   

G4 = 2 and SI

   • G5 = 0.74 (0.52-1.05)

 
   

G5 = 2 and AI

   • G6 = 0.56 (0.33-0.96)

 
   

G6 = 2 and FI

   • G7 = 0.94 (0.60-1.47)

 
   

G7 = 3 and SI

   • G8 = 0.87 (0.61-1.23)

 
   

G8 = 3 and AI

   • G9 = 0.48 (0.28-0.83)

 
   

G9 = 3 and FI

   • G10 = 0.88 (0.40-1.88)

 
   

G10 = 4 and SI

   • G11 = 0.64 (0.44-0.95)

 
   

G11 = 4 and AI

   • G12 = 0.38 (0.21-0.69)

 
   

G12 = 4 and FI

  

Kushi et al 1997 [65]

To evaluate the association between PA and all-cause mortality in postmenopausal women.

• n = 40,417

7 year follow-up

• 2,260 deaths

The results demonstrate a graded inverse association between PA and all-cause mortality in postmenopausal women.

  

• Sex: Women

   
  

• Age: 55-69 yr

PA assessment: Questionnaire for frequency of moderate and vigorous LTPA

Multivariate adjusted Frequency of moderate PA per week RR (95% CI):

 

USA

 

• Characteristics: Postmenopausal Iowa women

   

Prospective cohort

     
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.71 (0.63-0.79)

 

D & B score = 13

  

Divided by frequency/week

• G3 = 0.63 (0.56-0.71)

 
    

• G4 = 0.59 (0.51-0.67)

 
   

G1 = Rarely/never

Trend p = <0.001

 
   

G2 = 1 time/week to a few times/month

  
    

Frequency of vigorous PA per week

 
   

G3 = 2-4 times/week

  
   

G4 = >4 times/week

• G1 = 1.00 (referent)

 
    

• G2 = 0.83 (0.69-0.99)

 
    

• G3 = 0.74 (0.59-0.93)

 
   

Activity index

• G4 = 0.62 (0.42-0.90)

 
   

G1 = Low

Trend p = 0.009

 
   

G2 = Medium

  
   

G3 = High

  
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.77 (0.69-0.86)

 
    

• G3 = 0.68 (0.60-0.77)

 
    

Trend p = <0.001

 

Paffenbarger et al 1993 [67]

To analyze changes in the lifestyles of Harvard College alumni and the association of these changes with mortality.

• n = 10,269

Baseline (1977) and 8 year follow-up (1985)

• 476 deaths

Beginning moderately vigorous sports activity was associated with lower rates of death from all causes among middle aged and older men.

  

• Sex: Men

   
  

• Age: 45-84 yr (in 1977)

 

Beginning moderate sports activity was associated with 23% lower risk of death (95% CI 4%-42%, p = 0.015) than those not taking up moderate activity

 

USA

 

• Characteristics: Participants with no reported life- threatening disease

PA Assessment: Questionnaire -- blocks walked daily, stairs climbed daily and type, frequency and duration of weekly sports and recreational activities

  

Prospective cohort

     

D & B score = 13

     
   

Physical activity index (kcal/wk)

  
   

Sports and recreational activities

  
   

Light <4.5 METs

  
   

Moderate >4.5 METs

  
   

Weekly lists of deaths were obtained from the Harvard college alumni office

  
   

Proportional hazard models with Poisson regression methods

  

Katzmarzyk and Craig 2002 [154]

To quantify the relationship between musculoskeletal fitness and all-cause mortality.

• n = 8,116 (3,933 male; 4,183 female)

Baseline (1981) and

• 238 deaths

Some components of musculoskeletal fitness are predictive of mortality.

   

13 year follow-up

  
  

• Sex: Men and women

 

RR (95% CI) adjusted for age, smoking status, body mass and VO2max

 

Canada

  

Musculoskeletal fitness (sit ups, push ups, grip strength, sit and reach) measures divided into quartiles

  
  

• Age: 20-69 yr

Q1 = lowest

Sit ups

 

Prospective cohort

 

• Characteristics: Participants who had musculoskeletal fitness measurements taken

Q2

Men

 
   

Q3

• Q1 = 2.72 (1.56-4.64)

 
   

Q4 = highest

• Q2 = 1.32 (0.73-2.41)

 

D & B score = 11

   

• Q3 = 1.61 (0.90-2.87)

 
    

• Q4 = 1.00 (referent)

 
  

• Canadian Fitness Survey

   
   

Cox proportional hazard ratio model

Women

 
    

• Q1 = 2.26 (1.15-4.43)

 
    

• Q2 = 2.24 (1.07-4.67)

 
    

• Q3 = 1.27 (0.59-2.72)

 
    

• Q4 = 1.00 (referent)

 
    

Push-ups

 
    

Men

 
    

• Q1 = 1.25 (0.77-2.05)

 
    

• Q2 = 1.17 (0.71-1.90)

 
    

• Q3 = 0.94 (0.55-1.62)

 
    

• Q4 = 1.00 (referent)

 
    

Women

 
    

• Q1 = 0.61 (0.32-1.17)

 
    

• Q2 = 0.81 (0.45-1.47)

 
    

• Q3 = 0.87 (0.48-1.58)

 
    

• Q4 = 1.00 (referent)

 
    

Grip strength (kg)

 
    

Men

 
    

• Q1 = 1.49 (0.86-2.59)

 
    

• Q2 = 1.42 (0.82-2.45)

 
    

• Q3 = 1.59 (0.95-2.68)

 
    

• Q4 = 1.00 (referent)

 
    

Women

 
    

• Q1 = 1.08 (0.58-1.99)

 
    

• Q2 = 0.62 (0.44-1.56)

 
    

• Q3 = 1.25 (0.70-2.23)

 
    

• Q4 = 1.00 (referent)

 
    

Sit and reach (cm)

 
    

Men

 
    

• Q1 = 1.06 (0.64-1.74)

 
    

• Q2 = 1.01 (0.61-1.66)

 
    

• Q3 = 1.20 (0.74-1.95)

 
    

• Q4 = 1.00 (referent)

 
    

Women

 
    

• Q1 = 1.18 (0.66-2.10)

 
    

• Q2 = 1.07 (0.60-1.91)

 
    

• Q3 = 0.77 (0.44-1.46)

 
    

• Q4 = 1.00 (referent)

 

Andersen et al 2000 [163]

To evaluate the relationship between levels of OPA, LTPA, cycling to work and sports participation and all-cause mortality.

• n = 30,640 (17,265 men; 13,375 women)

14.5 year follow-up

• 8,549 deaths

LTPA was inversely associated with all-cause mortality in both men and women in all age groups.

   

PA assessment: Questionnaire for LTPA, divided into:

Incidence of all-cause mortality and PA

 

Denmark

 

• Sex: Men and women

   

Prospective cohort

 

• Age: 20-93 years (yr)

 

Multivariate adjusted RR (95% CI)

 
   

G1 = Low

  
  

• Characteristics: Participants of the Copenhagen City Heart Study, Glostrup Population Study and Copenhagen Male Study

G2 = Moderate

  

D & B score = 13

  

G3 = High

Age 20-44 yr

 
    

Men

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.73 (0.56-0.96)

 
    

• G3 = 0.74 (0.55-1.01)

 
    

Women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.75 (0.54-1.04)

 
    

• G3 = 0.66 (0.42-1.05)

 
    

Age 45-64 yr

 
    

Men

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.75 (0.67-0.84)

 
    

• G3 = 0.75 (0.67-0.85)

 
    

Women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.73 (0.65-0.83)

 
    

• G3 = 0.66 (0.56-0.77)

 
    

Age >65 yr

 
    

Men

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.62 (0.53-0.73)

 
    

• G3 = 0.60 (0.50-0.72)

 
    

Women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.52 (0.45-0.61)

 
    

• G3 = 0.49 (0.39-0.61)

 
    

All age groups

 
    

Men

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.72 (0.66-0.78)

 
    

• G3 = 0.71 (0.65-0.78)

 
    

Women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.65 (0.60-0.71)

 
    

• G3 = 0.59 (0.52-0.67)

 

Barengo et al 2004 [164]

To investigate whether moderate or high LTPA are associated with reduced CVD and all-cause mortality, independent of CVD risk factors and other forms of PA in men and women.

• n = 31,677 (15,853 men; 16,824 women)

20 year follow-up

HRR (95% CI)

Moderate and high levels of LTPA and OPA are associated with reduced premature all-cause mortality.

  

• Sex: Men and women

PA assessment: Questionnaire self administered to measure OPA, LTPA and commuting activity

LTPA

 

Finland

 

• Age: 30-59 yr

 

   • 1.00 (referent) = low

 
  

• Characteristics: Participants from eastern and south-western Finland

 

   • 0.91 (0.84-0.98) = mod, Men

 

Prospective cohort

     
    

   • 0.79 (0.70-0.90) = high, Men

 

D & B score = 14

   

   • 0.89 (0.81-0.98) = mod, women

 
    

   • 0.98 (0.83-1.16) = high, women

 
    

OPA

 
    

   • 1.00 (referent) = low

 
    

   • 0.75 (0.68-0.83) = mod, men

 
    

   • 0.77 (0.71-0.84) = active, men

 
    

   • 0.79 (0.70-0.89) = mod, women

 
    

   • 0.78 (0.70-0.87) = active, women

 

Bath 2003 [165]

To examine differences between older men and women on the self-rated health mortality relationship.

• n = 1,042 (406 men; 636 women at baseline)

Baseline, 4 and 12 years post

Number of deaths: At 4 years 242 (106 men; 136 women)

The self-rated health-mortality relationship can be explained by health and related factors among older men and women.

UK

 

• Sex: Men and women

 

• At 12 years 665 (287 men; 378 women)

 

Prospective cohort

 

• Age: >65 yr

   
  

• Characteristics: Community-dwelling Elderly

General physical health

14-item health index (Ebrahin et al 1987) scoring from 0-14 (no health problems -- multiple health problems)

Multivariate adjusted HR (95% CI)

 

D & B score = 11

     
  

• The Nottingham Longitudinal Study of Activity and Ageing

   
    

Men after 4 years

 
    

• High = 1.00 (referent)

 
    

• Med = 1.19 (0.61-2.33)

 
   

PA assessment: Self-rated health surveys, divided into 3 levels of PA:

• Low = 1.51 (0.75-3.03)

 
   

High

Women after 4 years

 
   

Medium

• High = 1.00 (referent)

 
   

Low

• Med = 1.03 (0.58-1.82)

 
    

• Low = 1.51 (0.86-2.67)

 
    

Men after 12 years

 
   

Cox proportional hazards regression Models

• High = 1.00 (referent)

 
    

• Med = 1.28 (0.94-1.74)

 
    

• Low = 1.13 (0.82-1.55)

 
    

Women after 12 years

 
    

• High = 1.00 (referent)

 
    

• Med = 1.20 (0.90-1.61)

 
    

• Low = 1.23 (0.93-1.62)

 

Bijnen et al 1998 [166]

To describe the association between PA and mortality (CVD, stroke, all-cause) in elderly men.

• n = 802

10 year follow-up

• 373 deaths

PA may protect against all- cause mortality in elderly men

  

• Sex: Men

   
  

• Age: 64-84 yr

PA assessment: Questionnaire, divided into groups:

Multivariate adjusted RR (95% CI)

 

Netherlands

 

• Characteristics: Retired Dutch men

   
    

• G1 = 1.00 (referent)

 

Prospective cohort

  

G1 = Lowest

• G2 = 0.80 (0.63-1.02)

 
   

G2 = Middle

• G3 = 0.77 (0.59-1.00)

 
   

G3 = Highest

p = 0.04

 

D & B score = 12

     

Blair et al 1993 [167]

To evaluate the relationship of sedentary living habits to all-cause mortality in women.

• n = 3,120

Baseline and 8 year follow-up

• 43 deaths

There is a graded inverse relationship between PF and all-cause mortality in women.

  

• Sex: Women

   
  

• Age: Not available

 

Age adjusted death rates (per 10,000 person years) by fitness

 

USA

 

• Characteristics: Participants were given a preventative medicine examination

PF assessment: PF measured via maximal treadmill exercise test;

  

Prospective

   

   • Low Fitness = 40

The lack of relationship between PA and death rate was believed to be due to an inadequate assessment of PA.

    

   • Mod Fitness = 16

 

D & B score = 14

   

   • High Fitness = 7

 
   

PA assessment: Questionnaire

  
    

No difference between levels of PA

 

Blair et al 1996 [168]

To review the association of PF to all-cause and CVD mortality.

• n = 32,421 (25,341 men; 7,080 women)

Baseline and average 8 year follow-up (range 0.1-19.1 years)

• 601 deaths in men

The study observed a steep inverse gradient of death rates across low, moderate and high PF levels. The association was strong and remained after adjustment for potential confounding factors.

    

• 89 deaths in women

 
  

• Sex: Men and women

   

USA

 

• Age: 20-80 yr (mean 43 yr)

 

RR (95% CI) in low PF vs.

 
   

PF assessment: Treadmill test; duration was used to assign participants to sex specific groups:

high PF

 

Prospective cohort

 

• Characteristics: Participants were excluded if they did not reach 85% of their age predicted maximal heart rate on the maximal exercise treadmill test

 

Men

 
    

• 1.52 (1.28-1.82)

 
    

Women

 

D & B score = 14

   

• 2.10 (1.36-3.26)

 
   

Low (least fit 20%)

Adjusted deaths per 10,000 person years according to PF

 
   

Moderate (next 40%)

  
   

High (most fit 40%)

Men

 
  

• Aerobics Center Longitudinal Study

Proportional hazard modeling

• Low = 49

 
    

• Med = 27

 
    

• High = 23

 
    

Women

 
    

• Low = 29

 
    

• Med = 13

 
    

• High = 14

 

Boyle et al 2007 [169]

To examine the association between PA and the risk of incident disability, including impairment in activities of daily living and instrumental activities of daily living in community based older persons free from dementia.

• n = 1,020

2.6 year follow-up

• 156 deaths

The risk of death decreased 11% with each hour of PA/wk.

  

• Sex: Men and women

   
  

• Age: 54-100 yr

PA assessment: Questionnaire, hr/wk of PA Incidence of all-cause mortality

HR for all-cause mortality

 

USA

 

• Characteristics: Participants from 40 retirement communities across Chicago

 

The risk of death was 11% lower for each hr/wk of PA

 

Prospective cohort

     

D & B score = 13

 

• Rush Memory and Aging Project

   

Bucksch et al 2005 [170]

To examine the effect of moderately intense PA on all-cause mortality.

• n = 7,187 (3,742 men; 3,445 women)

Baseline (1984-1986) and 12-14 yr follow-up (1998)

• 943 deaths

Participants who achieved recommended amounts of MPA or VPA were at a significantly lower risk of death than their sedentary counterparts.

  

• Sex: Men and women

 

RR (95% CI) for achieving recommended PA vs. not achieving recommendation

 

Germany

 

• Age: 30-69 yr

   

Prospective cohort

 

• Characteristics: Participants were healthy and physically active during leisure time

PA assessment: Questionnaire (Minnesota Leisure Time Physical Activity questionnaire) divided into groups based on: Achieving recommended amount of MPA (30 min, 5 d/wk (≥2.5 h/wk))

  
    

Women

 
    

• MPA = 0.65 (0.51-0.82)

 

D & B score = 13

   

• VPA = 0.78 (0.57-1.08)

 
    

• MPA or VPA = 0.60 (0.47-0.75)

 
    

Men

 
    

• MPA = 0.90 (0.77-1.01)

 
    

• VPA = 0.74 (0.61-0.90)

 
    

• MPA or VPA = 0.80 (0.68-0.94)

 
   

Achieving recommended amount of VPA (20 min, 3 d/wk (≥ 1 h/wk))

  
    

RR (95% CI) for volume of lifestyle activities (kcal/kg/wk)

 
   

Volume of lifestyle activities (kcal/kg/wk)

Women

 
   

G1 = 0

• G1 = 1.00 (referent)

 
   

G2 = <14

• G2 = 0.79 (0.57-1.08)

 
   

G3 = 14-33.5

• G3 = 0.68 (0.50-0.94)

 
   

G4 = ≥ 33.5

• G4 = 0.57 (0.41-0.79)

 
    

p < 0.001

 
    

Men

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.98 (0.76-1.17)

 
    

• G3 = 0.80 (0.63-1.00)

 
    

• G4 = 0.91 (0.74-1.13)

 
    

p = 0.20

 
    

Adjusted for age, other recommendation, social class, smoking, BMI, cardio risk factor index, alcohol intake, chronic disease index and dietary factors

 

Bucksch and Helmert 2004 [171]

To examine LTPA and premature death in the general population of former West Germany.

• n = 7,187 (3,742 men; 3,445 women)

Baseline (1984-1986) and 12-14 year follow-up (1998)

• 943 deaths

LTPA is inversely associated with all-cause mortality in men and women.

  

• Sex: Men and women

 

RR (95% CI)

 
  

• Age: 30-69 yr

 

Men, LTPA

 

Germany

 

• Characteristics: Participants were selected on the basis of the German Cardiovascular Prevention Study

PA assessment: Questionnaire (Minnesota Leisure Time Physical Activity questionnaire) divided into groups based on: LTSA (h/wk)

• G1 = 1.00 (referent)

 
    

• G2 = 0.85 (0.78-0.93)

 

Prospective cohort

   

• G3 = 0.64 (0.50-0.82)

 
    

• G4 = 0.70 (0.54-0.91)

 
    

p < 0.001

 

D & B score = 14

 

• The National Health Survey of the German Federal Institute of Population Research (1984-1998)

 

Men, LTPA index

 
   

G1 = 0

• G1 = 1.00 (referent)

 
   

G2 = <1

• G2 = 0.92 (0.70-1.23)

 
   

G3 = 1-2

• G3 = 0.89 (0.69-1.17)

 
   

G4 = >2

• G4 = 0.61 (0.44-0.84)

 
    

p <0.01

 
   

The LTSA-index (kcal/kg/wk)

  
   

G1 = 0

Women, LTPA

 
   

G2 = 1-10

• G1 = 1.00 (referent)

 
   

G3 = 10-25

• G2 = 0.93 (0.82-1.04)

 
   

G4 = >25

• G3 = 0.69 (0.48-0.98)

 
    

• G4 = 0.57 (0.35-0.94)

 
   

Mortality -- Records from the mandatory population registries

p < 0.01

 
    

Women, LTPA index

 
    

• G1 = 1.00 (referent)

 
   

Cox proportional hazard regression model

• G2 = 0.68 (0.45-1.01)

 
    

• G3 = 0.79 (0.51-1.21)

 
    

• G4 = 0.46 (0.25-0.85)

 
    

p < 0.01

 
    

Adjusted for age, social class, smoking, BMI, cardio risk factor index, alcohol intake, chronic disease index and dietary factors

 

Carlsson et al 2006 [172]

To investigate the association between PA and mortality in post-menopausal women.

• n = 27,734

Baseline (1997) and 2-7 year follow-up (1999-2004)

• 1,232 deaths

The study indicates that even fairly small amounts of activity will reduce mortality in older women.

  

• Sex: Women

   
  

• Age: 51-83 yr

 

RR (95% CI) adjusted for lifestyle and medical problems

 

Sweden

 

• Characteristics: Women who participated in a population based Screening programme in 1987

   

Prospective cohort

  

PA assessment: Questionnaires for: METs/day, different PA (walking/biking), LTPA, OPA, household PA, TV watching and reading

  
    

PA (METs/day)

 
    

• >50 = 1.00 (referent)

 

D & B score = 12

   

• 45-50 = 1.05 (0.77-1.42)

 
  

• The Swedish Mammography Cohort

 

• 40-45 s = 1.09 (0.81-1.46)

 
    

• 45-40 = 1.26 (0.94-1.70)

 
    

• <35 = 2.56 (1.85-3.53)

 
   

Mortality -- Records from the National Population Register

  
    

Different PA

 
    

Walking/biking (min/d)

 
    

• > 90 = 1.00 (referent)

 
    

• 60-90 = 1.01 (0.76-1.34)

 
    

• 40-60 = 0.92 (0.70-1.20)

 
    

• 20-40 = 0.96 (0.75-1.23)

 
    

• <20 = 1.16 (0.90-1.50)

 
    

• Almost never = 1.94 (1.51-2.50)

 
    

LTPA (hr/wk)

 
    

• >5 = 1.00 (referent)

 
    

• 4-5 = 0.95 (0.74-1.22)

 
    

• 2-3 = 1.02 (0.83-1.26)

 
    

• 1 = 1.09 (0.88-1.36)

 
    

• <1 = 1.91 (1.56-2.35)

 
    

OPA

 
    

• Heavy manual labour = 1.00 (referent)

 
    

• Walking/lifting/ a lot carrying = 0.96 (0.55-1.70)

 
    

• Walking/lifting/ not a lot carrying = 1.00 (0.60-1.68)

 
    

• Mostly standing = 0.91 (0.52-1.61)

 
    

• Seated 50% of time = 0.97 (0.58-1.62)

 
    

• Mostly sedentary = 1.93 (1.15-3.25)

 
    

Household work (hr/d)

 
    

• >8 h/d = 1.00 (referent)

 
    

• 7-8 = 0.68 (0.49-0.93)

 
    

• 5-6 = 0.66 (0.51-0.87)

 
    

• 3-4 = 0.83 (0.64-1.06)

 
    

• 1-2 = 0.89 (0.69-1.15)

 
    

• <1 = 1.73 (1.30-2.32)

 
    

Adjusted for age

 

Crespo et al 2002 [173]

To study the relationship between PA and obesity with all- cause mortality in Puerto Rican men.

• n = 9,136 (1962-1965)

Baseline and 12 year follow-up

• 1,445 deaths

Some PA is better than none in protecting against all-cause mortality. The benefits are independent of body weight.

Puerto Rico

 

• Sex: Men

PA assessment: Questionnaire, divided into 4 groups based on METs

Multivariate OR (95% CI) adjusted for age

 
   

G1 = low

  
   

G2

  
   

G3

  
   

G4 = high

  

Prospective cohort

 

• Age: 35-79 yr

Multivariate logistic function model

• C1 = 1.00 (referent)

 

D & B score = 12

 

• Characteristics: Participants with no known coronary heart disease

 

• C2 = 0.67 (0.57-0.78)

 
  

• The Puerto Rico Heart Health Program

 

• C3 = 0.63 (0.54-0.74)

 
    

• C4 = 0.54 (0.46-0.64)

 
    

p < 0.0001

 
    

Multivariate adjusted OR (95% CI)

 
    

• C1 = 1.00 (referent)

 
    

• C2 = 0.68 (0.58-0.79)

 
    

• C3 = 0.63 (0.54-0.75)

 
    

• C4 = 0.55 (0.46-0.65)

 
    

p < 0.0001

 

Davey Smith et al

2000 [174]

To examine the relationship of PA and various causes of death.

• n = 6,702 (at baseline)

Baseline (1969-1970) and 25 year follow-up

• 926 deaths

In the study, an inverse association of both LTPA and walking pace with mortality from all-causes was seen.

UK

 

• Sex: Men

PA assessment: Questionnaire with 3 groups for walking pace (Slower, same, faster) and 3 groups for LTPA (inactive, moderately active, active)

Age adjusted RR (95% CI) for walking pace

 

Prospective cohort

 

• Age: 40-64 yr

 

• Slower = 2.47 (2.2-2.8)

 

D & B score = 13

 

• Characteristics: Participants from rural northern Japan

 

• Same = 1.35 (1.2-1.5)

 
  

• Whitehall study

 

• Faster = 1.00 (referent)

p < 0.001

 
    

Fully adjusted RR (95% CI) for walking pace

 
    

• Slower = 1.87 (1.6-2.1)

 
    

• Same = 1.21 (1.1-1.3)

 
    

• Faster = 1.00 (referent)

p < 0.001

 
    

Age adjusted RR (95% CI) for LTPA

 
    

• Inactive = 1.44 (1.3-1.6)

 
    

• Mod = 1.13 (1.0-1.2)

 
    

• Active = 1.00 (referent)

p < 0.001

 
    

Fully adjusted RR (95% CI) for LTPA

 
    

• Inactive = 1.20 (1.1-1.3)

 
    

• Mod = 1.07 (1.0-1.2)

 
    

• Active = 1.00 (referent)

p < 0.001

 

Eaton et al 1995 [175]

To determine whether self-reported PA predicts a decreased rate of CHD and all- cause mortality in middle aged men.

• n = 8,463

21 year follow-up

• 2,593 deaths

Baseline levels of self- reported LTPA predicted a decreased rate of CHD and all-cause mortality.

Europe, Israel, mid eastern Asia, Northern Africa

 

• Sex: Men

PA assessment: Questionnaire for LTPA

Age adjusted RR (95% CI) LTPA

 

Prospective cohort

 

• Age: ≥40 yr

G1 = Sedentary

• G1 = 1.00 (referent)

 

D & B score = 12

 

• Characteristics: Government employees without known CVD

G2 = Light

• G2 = 0.84 (0.74-0.94)

 
   

G3 = Light daily

• G3 = 0.81 (0.73-0.90)

 
   

G4 = Heavy

• G4 = 0.84 (0.72-0.98)

 
    

OPA

 
   

Questionnaire for OPA

• G1 = 1.00 (referent)

 
   

G1 = Sitting

• G2 = 0.99 (0.88-1.12)

 
   

G2 = Standing

• G3 = 1.09 (0.99-1.20)

 
   

G3 = Walking

• G4 = 1.16 (1.03-1.30)

 
   

G4 = Physical labour

  

Fang et al 2005 [176]

To assess the association of exercise and CVD outcome among persons with different blood pressure status.

• n = 9,791 (3,819 men; 5,972 women)

17 year follow-up

Incidence of all-cause mortality and PA

A significant effect of exercise on mortality in normotensive subjects was not found.

USA

 

• Sex: Men and women

PA assessment: Questionnaire with 3 groups

Multivariate adjusted HR (95% CI)

 

Prospective cohort

 

• Age:25-74 yr

G1 = Least exercise

• G1 = 1.00 (referent)

 

D & B score = 12

 

• Characteristics: Non- institutionalized participants

G2 = Moderate exercise

• G2 = 0.75 (0.53-1.05)

 
   

G3 = Most exercise

• G3 = 0.71 (0.45-1.12)

 

Fried et al 1998 [177]

To determine the disease, functional and personal characteristics that jointly predict mortality.

• n = 5,886

5 year follow-up

• 646 deaths

PA was a predictor of 5-year mortality.

USA

 

• Sex: Men and women

PA assessment: Self reported exercise (5 groups)

Incidence of all-cause mortality and PA

 

Prospective cohort

 

• Age: ≥65 yr

MPA or VPA (kJ/wk)

Multivariate adjusted RR (95% CI)

 

D & B score = 11

 

• Characteristics: Community dwelling elders

G1 = ≤282

• G1 = 1.00 (referent)

 
   

G2 = 283-1789

• G2 = 0.78 (0.60-1.00)

 
   

G3 = 1790-4100

• G3 = 0.81 (0.63-1.05)

 
   

G4 = 4101-7908

• G4 = 0.72 (0.55-0.93)

 
   

G5 = >7908

• G5 = 0.56 (0.43-0.74)

p < 0.005

 

Fujita et al 2004 [178]

To examine the relationship between walking duration and all-cause mortality in a Japanese cohort.

• n = 41,163 (20,004 men; 21,159 women)

Baseline (1990) and 11 year follow-up (2001)

• 1,879 deaths

Time spent walking was associated with a reduced risk for all-cause mortality.

Japan

 

• Sex: Men and women

PA assessment: Questionnaire Walking, 3 levels:

Age and sex adjusted RR (95% CI) for time spent walking (hr/d)

 
   

G1 = ≤30 min

  
   

G2 = 30 min to 1 hr

  
   

G3 = ≥1 hr

  

Prospective cohort

 

• Age: 40-64 yr

Cox proportional hazard model

Whole group

 

D & B score = 13

 

• Characteristics: Healthy, sedentary

 

• G1 = 1.22 (1.09-1.35)

 
    

• G2 = 1.09 (0.95-1.22)

 
    

• G3 = 1.00 (referent)

p < 0.001

 
    

Men only

 
    

• G1 = 1.14 (1.00-1.30)

 
    

• G2 = 1.03 (0.90-1.19)

 
    

• G3 = 1.00 (referent p = 0.061

 
    

Women only

 
    

• G1 = 1.40 (1.16-1.68)

 
    

• G2 = 1.23 (1.01-1.49)

 
    

• G3 = 1.00 (referent)

p < 0.001

 
    

RR (95% CI) for time spent walking (hr/d) (adjusted for age, education, marital status, past history of diseases, smoking, drinking, BMI and dietary variables)

 
    

Whole group

 
    

• G1 = 1.17 (1.04-1.31)

 
    

• G2 = 1.06 (0.93-1.20)

 
    

• G3 = 1.00 (referent)

p = 0.011

 
    

Men

 
    

• G1 = 1.08 (0.94-1.25)

 
    

• G2 = 0.98 (0.84-1.14)

 
    

• G3 = 1.00 (referent)

p = 0.318

 
    

Women

 
    

• G1 = 1.38 (1.12-1.70)

 
    

• G2 = 1.24 (1.00-1.54)

 
    

• G3 = 1.00 (referent)

p < 0.001

 

Glass et al 1999 [179]

To examine any association between social activity, productive activity and PA and mortality in older people.

• n = 2,761 (1,169 men; 1,143 women)

13 year follow-up

Incidence of all-cause mortality by fitness activity quartile

More active elderly people were less likely to die than those who were less active.

USA

 

• Sex: Men and women

PA assessment: Interview, Amount of activity

13 yr mortality by amount of activity

 

Prospective cohort

 

• Age: ≥ 65 yr

G1 = Low

• G1 = 74.0

 

D & B score = 12

 

• Characteristics: Healthy elders

G2 = Low-medium

• G2 = 69.8

 
   

G3 = Medium-high

• G3 = 62.4

 
   

G4 = High

• G4 = 55.2

 

Gulati et al 2003 [180]

To determine whether exercise capacity is a predictor for all-cause mortality in asymptomatic women.

• n = 5,721

Baseline (1992) and 8 year follow-up (2000)

• 180 deaths

This study confirmed that exercise capacity is an independent predictor of death in asymptomatic women, greater than what has been previously established among men.

USA

 

• Sex: Women

PF Assessment: Treadmill stress test Exercise capacity (METs)

G1 = <5

G2 = 5-8

G3 = >8

For every 1 MET increase there was a reduced death risk of 17% (p < 0.001)

 

Prospective cohort

 

• Age: Mean 52 ± 11 yr

 

Age-adjusted RR

 

D & B score = 11

 

• Characteristics: Asymptomatic women

 

• G1 = 2.0 (1.3-3.2)

 
  

• St James Women Take Heart Project

 

• G2 = 1.6 (1.1-2.4)

 
    

• G3 = 1.00 (referent)

 
    

Adjusted for Framingham

Risk Score

 
    

• G1 = 3.1 (2.1-4.8)

 
    

• G2 = 1.9 (1.3-2.9)

 
    

• G3 = 1.00 (referent)

 

Haapanen et al 1996 [181]

To examine the association between LTPA and all-cause mortality.

• n = 1,072

Baseline and a 10 yr

10 month follow-up

• 168 deaths

Low PA is a risk factor for all-cause mortality.

Finland

 

• Sex: Men

PA assessment: Self-reported LTPA, divided into 4 groups by EE (kJ/wk)

G1 = 0-3349

G2 = 3350-6279

G3 = 6280-8791

G4 = >8791

RR (95% CI) according to EE group

 

Prospective cohort

 

• Age: 35-63 yr

Mortality--National

Death Index search

• G1 = 2.74 (1.46-5.14)

 

D & B score = 14

 

• Characteristics: Healthy, sedentary

Cox proportional HR

• G2 = 1.10 (0.55-2.21)

 
    

• G3 = 1.74 (0.87-3.50)

 
    

• G4 = 1.00 (referent)

 

Hakim et al 1998 [182]

To examine the association between walking and mortality in retired men.

• n = 707

Baseline and 12 yr follow-up

• 208 deaths

The findings in older physically capable men indicate that regular walking is associated with a lower overall mortality rate.

USA

 

• Sex: Men

 

RR (95% CI) according to distance walked

 

Prospective cohort

 

• Age: 61-81 yr

 

Adjusted for age

 

D & B score = 12

 

• Characteristics: Retired non-smoking men who were physically capable of participating in low intensity activities on a daily basis

PA assessment: Questionnaire Distance walked (miles/day)

• G1 vs. G3 = 1.9 (1.3-2.9)

 
   

G1 = 0.0-0.9

• G1 vs. G3 = 1.6 (1.2-2.2)

 
   

G2 = 1.0-2.0

• G2 vs. G3 = 1.2 (0.8-1.7)

 
   

G3 = 2.1-8.0

Trend p = 0.002

 
  

• Honolulu Heart Program

   
    

Adjusted for risk factors

 
    

• G1 vs. G3 = 1.8 (1.2-2.7)

 
    

• G1 vs. G2 = 1.5 (1.1-2.1)

 
    

• G2 vs. G3 = 1.1 (0.8-1.7)

 
    

Trend p = 0.01

 

Hillsdon et al 2004 [183]

To examine whether VPA is associated with all-cause mortality.

• n = 10,522 (4,929 men; 5,593 women)

>10 year follow-up

• 825 deaths

Questionnaire respondents who reported engaging in VPA less than twice a week experienced a 37% reduced risk of all-cause mortality compared with respondents who reported a lower frequency of VPA.

  

• Sex: Men and women

PA assessment: Questionnaire for frequency of VPA

Age and sex adjusted RR (95% CI)

 

UK

 

• Age: 35-64 yr

G1 = Never, <1 time/month

  
  

• Characteristics: Healthy, sedentary

G2 = <2 times/wk

• G1 = 1.00 (referent)

 

Prospective Cohort

 

• OXCHECK study

G3 = >2 times/wk

• G2 = 0.57 (0.42-0.79)

 
    

• G3 = 0.72 (0.54-0.95)

 

D & B score = 11

   

Fully adjusted RR (95% CI)

 
    

• G1 = 1.00 (referent)

 
   

Mortality -- Recorded from the Office of National Statistics

• G2 = 0.63 (0.45-0.89)

 
    

• G3 = 0.81 (0.60-1.09)

 
   

Cox proportional HR

  

Hu et al 2005 [184]

To examine the association of PA and BMI and their combined effect with the risk of total, CVD and cancer mortality.

• n = 47,212 (22,528 men; 24,684 women)

17.7 year follow-up

• 7,394 deaths

Regular PA is an important indicator for decreased risk of all-cause mortality. PA has a strong independent effect on mortality.

  

• Sex: Men and women

   

Finland

 

• Age:25-64 yr

PA assessment: Questionnaire for PA level, divided into 3 groups

Adjusted HR (95% CI)

 
  

• Characteristics: Participants from eastern Finland

 

Men

 

Prospective cohort

   

• G1 = 1.00 (referent)

 
    

• G2 = 0.74 (0.68-0.81)

 
   

G1 = Low

• G3 = 0.63 (0.58-0.70)

 

D & B score = 12

  

G2 = Moderate

Trend p = <0.001

 
   

G3 = High

  
    

Women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.64 (0.58-0.70)

 
    

• G3 = 0.58 (0.52-0.64)

 
    

Trend p = <0.001

 

Hu et al 2004 [185]

To examine the association of BMI and PA with death.

• n = 116,564

Baseline (1976) and

• 10,282 deaths

Reduced PA is a strong and independent predictor of death.

  

• Sex: Women

24 year follow-up

  
  

• Age: 30-55 yr

 

Multivariate RR (95% CI) by PA (hr/wk)

 

USA

 

• Characteristics: Females free of known CVD and cancer

PA assessment: Questionnaire for PA level, divided into 3 groups (hr/week)

• G1 = 1.00 (referent)

 
   

G1 = ≥ 3.5

• G2 = 1.18 (1.10-1.26)

 

Prospective cohort

  

G2 = 1.0-3.4

• G3 = 1.52 (1.41-1.63)

 

D & B score = 11

  

G3 = <1.0

Multivariate RR (95% CI) by PA adjusted for BMI

 
    

• G1 = 1.00 (referent)

 
   

BMI (kg/m2)

• G2 = 1.14 (1.06-1.22)

 
   

G1 = <25

• G3 = 1.44 (1.34-1.55)

 
   

G2 = 25-29

  
   

G3 = 30

  
   

Cox proportional HR

  

Kampert et al 1996 [186]

To examine PF and PA in relation to all-cause and cancer mortality.

• n = 32,421 (25,341 men; 7,080 women)

Baseline (1970) and ~8 year follow-up (1989)

• 690 deaths

The data support the hypothesis that an active and fit way of life delays death.

  

• Sex: Men and women

 

Adjusted RR (95% CI) by quintiles of activity

 

USA

 

• Age: 20-88 yr (mean ~43)

   

Prospective cohort

 

• Characteristics: Predominantly white and from the middle and upper socioeconomic strata

PA assessment: Questionnaire, divided into quintiles of activity (min/wk)

Men

 
    

• Sedentary = 1.00 (referent)

 
    

• C1-2 = 0.71 (0.58-0.97)

 

D & B score = 13

   

• C3 = 0.83 (0.59-1.16)

 
   

Male activity categories

• C4 = 0.57 (0.30-1.08)

 
    

• C5 = 0.92 (0.29-2.88)

 
   

Sedentary = 855

Trend p = 0.011

 
   

C1-2 = 1,072

  
   

C3 = 1,292

Women

 
   

C4 = 1,453

• Sedentary = 1.00 (referent)

 
   

C5 = 1,601

• C1-2 = 0.68 (0.39-1.17)

 
    

• C3 = 0.39 (0.09-1.65)

 
   

Females activity categories

• C4-5 = 1.14 (0.27-4.80)

 
   

Sedentary = 605

Trend p = 0.217

 
   

C1-2 = 792

  
   

C3 = 979

  
   

C4-5 = 1,158

  
   

Cox proportional HR

  

Kaplan et al 1996 [187]

To assess LTPA and its association with all cause mortality.

• n = 6,131 (3298 men; 2833 women)

28 year follow-up

• 1,226 deaths

The data provide further support for the importance of PA and indicate that the protective effect of PA is a robust one.

  

• Sex: Men and women

PA assessment: Three questions about PA, with scores 0 (never), 2 (sometimes) or 4 (often).

Incidence of all-cause mortality and PA

 

USA

 

• Age: 16-94 yr

   
  

• Characteristics: Northern Californian adults

   

Prospective cohort

   

Death rates/1000 person years

 
    

Men

 

D & B score = 13

   

• T1 = 24.68

 
   

Tertiles of PA score

• T2 = 11.37

 
   

T1 = 0-2

• T3 = 7.59

 
   

T2 = 4-6

Women

 
   

T3 = 8-12

• T1 = 18.03

 
    

• T2 = 7.66

 
    

• T3 = 3.88

 

Khaw et al 2006 [188]

To examine the relationship between PA patterns over 1 year and total mortality.

• n = 22,191 (9,984 men; 12,207 women)

8 year follow-up

• 1,553 deaths

Even very moderate levels of usual PA are associated with reductions in mortality.

  

• Sex: Men and women

PA assessment: Questionnaire, divided into 4 groups of PA

Incidence of all-cause mortality and PA

 

UK

 

• Age: 45-79 yr

 

Adjusted RR (95% CI)

 
  

• Characteristics: Community living participants

 

All

 

Prospective cohort

  

G1 = Inactive

• G1 = 1.00 (referent)

 
   

G2 = Moderately inactive

• G2 = 0.83 (0.73-0.95)

 

D & B score = 13

   

• G3 = 0.68 (0.58-0.80)

 
   

G3 = Moderately active

• G4 = 0.68 (0.57-0.81)

 
   

G4 = Active

Age <65

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 1.01 (0.78-1.31)

 
    

• G3 = 0.81 (0.62-1.07)

 
    

• G4 = 0.82 (0.62-1.09)

 
    

Age >65

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.77 (0.66-0.91)

 
    

• G3 = 0.65 (0.53-0.79)

 
    

• G4 = 0.64 (0.50-0.80)

 

Kohl et al 1996 [189]

To determine the association of maximal exercise hemodynamic responses with risk of all-cause mortality.

• n = 26,621 (20,387 men; 6,234 women)

Average 8.1 year follow-up

• 348 deaths in men and 66 in women

The results suggest an exaggerated SBP or an attenuated heart rate response to maximal exercise may indicate an elevated risk for mortality.

  

• Sex: Men and women

   

USA

 

• Age: Male mean 42.2 yr; female mean 41.9 Yr

 

Adjusted RH (95% CI) by maximal exercise test HR

 

Prospective cohort

   

Men

 
  

• Characteristics: Apparently healthy patients of a preventive medicine centre

PF assessment: Maximal exercise test HR (bpm), divided into 4 Groups:

• Q1 = 1.00 (referent)

 
   

G1 = <171

• Q2 = 0.61 (0.44-0.85)

 

D & B score = 12

  

G2 = 171-178

• Q3 = 0.69 (0.51-0.93)

 
   

G3 = 179-188

• Q4 = 0.60 (0.41-0.87)

 
   

G4 = >188

Trend p<0.05

 
    

Women

 
    

• Q1 = 1.00 (referent)

 
    

• Q2 = 1.23 (0.65-2.32)

 
    

• Q3 = 0.69 (0.30-1.63)

 
    

• Q4 = 0.71 (0.22-2.24)

 
    

Trend p>0.05

 

Kujala et al 1998 [190]

To investigate LTPA and mortality in a cohort of twins.

• n = 15,902 (7,925 men; 7,977 women)

Baseline 1975 and death outcome from 1977-1994

• 1,253 deaths

LTPA is associated with reduced mortality, even after genetic and other familial factors are taken into account.

  

• Sex: Men and women

 

HR (95% CI)

 

Finland

 

• Age: 25-64 yr

   
  

• Characteristics: Healthy, Finnish same sex twins

PA assessment: Questionnaire, quintiles of fitness in MET hours/day

Adjusted for age and sex

 

Prospective cohort

   

• Sedentary = 1.00 (referent)

 
    

• OE = 0.71 (0.62-0.81)

 
  

• The Finnish Twin Cohort

 

• CE = 0.57 (0.45-0.74)

 

D & B score = 13

  

Q1 = <58

Trend p = 0.001

 
   

Q2 = 59-1.29

  
   

Q3 = 1.30-2.49

Adjusted for age, sex, smoking

 
   

Q4 = 2.50-4.49

  
   

Q5 = >4.50

• Sedentary = 1.00 (referent)

 
    

• OE = 0.76 (0.67-0.87)

 
   

Categorized into:

• CE = 0.68 (0.53-0.88)

 
   

-Sedentary

  
   

-Occasional exerciser (OE)

Trend p = 0.001

 
   

-Conditioning exerciser (CE)

Adjusted for age, sex, smoking, occupational group, alcohol

 
    

• Sedentary = 1.00 (referent)

 
    

• OE = 0.80 (0.69-0.91)

 
    

• CE = 0.76 (0.59-0.98)

 
    

Trend p = 0.002

 
    

HR (95% CI) among 434 same sex twin pairs compared with sedentary category in 1975

 
    

• Sedentary = 1.00 (referent)

 
    

• OE = 0.66 (0.46-0.94)

 
    

• CE = 0.44 (0.23-0.83)

 
    

Trend p = 0.005

 
    

Adjusted for smoking

 
    

• Sedentary = 1.00 (referent)

 
    

• OE = 0.70 (0.48-1.01)

 
    

• CE = 0.56 (0.29-1.09)

 
    

Trend p = 0.04

 
    

Adjusted for smoking, occupational group, alcohol

 
    

• Sedentary = 1.00 (referent)

 
    

• OE = 0.73 (0.50-1.07)

 
    

• CE = 0.56 (0.29-1.11)

 
    

Trend p = 0.06

 
    

OR (95% CI) in quintiles among 434 same sex twin pairs compared with sedentary category in 1975

 
    

• Q1 = 1.00 (referent)

 
    

• Q2 = 0.85

 
    

• Q3 = 0.72

 
    

• Q4 = 0.68

 
    

• Q5 = 0.60

 

LaCroix et al 1996 [191]

To determine whether walking is associated with a reduced risk of CVD hospitalization and death in older adults.

• n = 1,645 (615 men; 1030 women)

4.2 year follow-up

RR (95% CI) by category of walking

Walking more than 4 hr/wk was associated with a reduced risk of mortality from all-causes.

  

• Sex: Men and women

PA assessment: Questionnaire for walking h/wk, divided into 3 groups

  

USA

 

• Age: ≥65 yr

G1 = <1 hr/week

Men

 
  

Characteristics: Participants from a group health co-operative

G2 = 1-4 hr/week

• G1 = 1.00 (referent)

 

Prospective cohort

  

G3 = >4 hr/week

• G2 = 0.78 (0.43-1.45)

 
    

• G3 = 0.89 (0.49-1.62)

 

D & B score = 12

   

Women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.50 (0.28-0.90)

 
    

• G3 = 0.48 (0.25-0.83)

 
    

Age 65-74 yr

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.81 (0.40-1.61)

 
    

• G3 = 1.13 (0.60-2.15)

 
    

Age ≥75 yr

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.63 (0.37-1.08)

 
    

• G3 = 0.46 (0.25-0.84)

 
    

High functioning

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.73 (0.38-1.41)

 
    

• G3 = 0.89 (0.48-1.65)

 
    

Limited functioning

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.60 (0.34-1.05)

 
    

• G3 = 0.51 (0.28-0.92)

 

Lam et al 2004 [192]

To investigate the relationship LTPA and mortality in Hong Kong.

• n = 24,079 cases (13,778 men; 10,301 women);

10 years prior

Multivariate adjusted OR (95% CI) by LTPA

The data confirm and extend previous findings in Caucasian populations on the association between LTPA and longevity.

   

PA assessment:

Men

 

Hong Kong

 

• n = 13,054 controls (3,918 men; 9,136 women)

Questionnaire for LTPA, divided into 3 groups

• G1 = 1.00 (referent)

 
    

• G2 = 0.60 (0.54-0.67)

 

Case-Control

   

• G3 = 0.66 (0.60-0.73)

 
  

• Sex: Men and women

G1 = <1 times per month

  

D & B score = 12

 

• Age: ≥35 yr

 

Women

 
  

• Characteristics: All ethnic Chinese

G2 = 1-3 times per month

• G1 = 1.00 (referent)

 
    

• G2 = 0.81 (0.74-0.88)

 
   

G3 = ≥4 times per month

• G3 = 0.71 (0.66-.077)

 

Lan et al 2006 [193]

To investigate the relationship between exercise and all-cause mortality.

• n = 2,113 (1,081 men; 1,032 women)

Baseline and 2 year follow-up

• 197 deaths

Older persons are recommended to expend at least 1000 kcal/wk through regular exercise for mortality reduction.

  

• Sex: Men and women

 

HR (95% CI) by LTPA frequency

 

Taiwan

 

• Age: ≥65 yr

PA assessment: Questionnaire for LTPA (frequency/wk)

  

Prospective cohort

 

• Characteristics: Non-institutionalized elders

 

Adjusted for age and sex

Protection of exercise against death also increases with the number of activities.

   

G1 = Sedentary

• G1 = 1.00 (referent)

 
  

• Taiwan National Health Interview Survey

G2 = 1 time/wk

• G2 = 0.49 (0.36-0.67)

 

D & B score = 13

  

G3 = ≥2 times/wk

• G3 = 0.20 (0.09-0.46)

 
    

Trend p = <0.001

 
   

Questionnaire for EE (kcal/wk), divided into 5 groups:

Multivariate adjusted

 
    

• G1 = 1.00 (referent)

 
   

G1 = Sedentary

• G2 = 0.70 (0.50-0.98)

 
   

G2 = <500

• G3 = 0.35 (0.15-0.82)

 
   

G3 = 500-999

Trend p = 0.014

 
   

G4 = 1000-1999

  
   

G5 = ≥2000

  
    

HR (95% CI) by EE

 
    

Adjusted for age and sex

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.64 (0.41-1.01)

 
    

• G3 = 0.55 (0.35-0.85)

 
    

• G4 = 0.30 (0.17-0.53)

 
    

• G5 = 0.24 (0.12-0.48)

 
    

Trend p <0.001

 
    

Multivariate adjusted

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.80 (0.49-1.30)

 
    

• G3 = 0.74 (0.46-1.17)

 
    

• G4 = 0.50 (0.27-0.90)

 
    

• G5 = 0.43 (0.21-0.87)

 
    

Trend p = 0.043

 

Laukkanen et al 2001 [194]

To examine the relationship between maximal oxygen uptake and overall mortality.

• n = 1,294

Baseline and 10.7 year follow-up

• 124 deaths

PF has a strong, graded, inverse association with overall mortality.

  

• Sex: Men

 

Adjusted RR (95% CI) by quartile

 

Finland

 

• Age: 42.0-61.3 yr (mean 52.1)

   
  

• Characteristics: Men free from CVD, COPD, and cancer at baseline

PF assessment: Exercise tolerance test, 4 groups by maximal oxygen uptake (ml/kg/min)

  

Prospective cohort

   

Maximal oxygen uptake

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 1.47 (0.71-3.01)

 

D & B score = 14

   

• G3 = 2.79 (1.44-5.39)

 
   

G1 = >37.1

• G4 = 3.85 (2.02-7.32)

 
   

G2 = 32.3-37.1

Linear trend p = <0.001

 
   

G3 = 27.6-32.2

  
   

G4 = <27.6

Test duration

 
    

• G1 = 1.00 (referent)

 
   

Test duration (min)

• G2 = 2.22 (1.08-4.55)

 
   

G1 = >11.2

• G3 = 2.23 (1.11-4.49)

 
   

G2 = 9.6-11.2

• G4 = 3.94 (2.01-7.74)

 
   

G3 = 8.2-9.5

Linear trend p<0.001

 
   

G4 = <8.2

  

Lee and Paffenbarger 2000 [195]

To compare various levels of PA with mortality.

• n = 13,485

Baseline and 15 year follow-up

• 2,539 deaths

The study provides some support for recommendations that emphasize MPA. A benefit of VPA is also evident.

  

• Sex: Men

   
  

• Age: Mean 57.5 yr

 

RR (95% CI)

 
  

• Characteristics: Men who matriculated as undergraduates in 1916-1950

PA assessment:

• G1 = 1.00 (referent)

 

USA

  

Questionnaires for LTPA index (including walking, stair climbing, sports and recreational activity),

• G2 = 0.80 (0.72-0.88)

 
    

• G3 = 0.74 (0.65-0.83)

 

Prospective cohort

   

• G4 = 0.80 (0.69-0.93)

 
  

• The Harvard Alumni Health Study

 

• G5 = 0.73 (0.64-0.84)

 
    

Trend p = <0.001

 

D & B score = 12

  

5 groups (kJ/wk)

  
   

G1 = <4200

  
   

G2 = 4200-8399

  
   

G3 = 8400-12599

  
   

G4 = 12600-16799

  
   

G5 = ≥ 16800

  

Lee et al 1995 [196]

To examine the independent association of vigorous and non-vigorous PA with longevity.

• n = 17,321

Follow-up 22-26 years

• 3,728 deaths

There is a graded inverse relationship between PA and mortality. Vigorous, but not non-vigorous activities are associated with longevity.

  

• Sex: Men

   
  

• Age: Mean 46 yr

PA assessment: Questionnaires for EE (kJ/wk), quintiles

RR (95% CI) by EE (kJ/wk)

 

USA

 

• Characteristics: Harvard University alumni, without self-reported physician diagnosed cardiovascular disease, cancer or chronic obstructive pulmonary disease

 

Q1= 1.00 (referent)

 
    

• Q2 = 0.94 (0.86--1.04)

 

Prospective cohort

  

Q1 = ≤ 630

• Q3 = 0.95 (0.86--1.05)

 
   

Q2 = 630-1680

• Q4 = 0.91 (0.83 - 1.01)

 
   

Q3 = 1680-3150

• Q5 = 0.91 (0.82-1.00)

 

D & B score = 12

  

Q4 = 3150-6300

  
   

Q5 = >6300

RR (95% CI) by EE (Vigorous activity, kJ/wk)

 
    

• Q1 = 1.00 (referent)

 
  

• The Harvard Alumni Health Study

 

• Q2 = 0.88 (0.82-0.96)

 
    

• Q3 = 0.92 (0.82-1.02)

 
    

• Q4 = 0.87 (0.77-0.99)

 
    

• Q5 = 0.87 (0.78-0.97)

 

Lee et al 2004 [197]

To investigate the effect of various PA patterns on all-cause mortality.

• n = 8,421

Baseline 1988 and follow-up 1993

• 1,234 deaths

The results suggest that regular PA generating 1000 kcal/wk or more should be recommended for lowering mortality rates. Among those with no major risk factors, even 1-2 episodes per week generating 1000 kcal or more can postpone mortality.

  

• Sex: Men

   
  

• Age: Mean 66 yr

 

Age adjusted RR (95% CI) by PA pattern

 

USA

 

• Characteristics: Participants free of major chronic disease

PA assessment: Questionnaire for PA (kcal/wk), 4 groups

  
    

• G1 = 1.00 (referent)

 

Prospective cohort

   

• G2 = 0.75 (0.63-0.90)

 
   

G1 = <500

• G3 = 0.82 (0.63-1.07)

 
  

• The Harvard Alumni Health Study

(Sedentary)

• G4 = 0.61 (0.53-0.69)

 

D & B score = 11

  

G2 = 500-999

  
   

(Insufficiently active)

Multivariate adjusted

 
   

G3 = ≥ 1000

  
   

(Weekend warrior)

• G1 = 1.00 (referent)

 
   

G4 = Regularly active

• G2 = 0.75 (0.62-0.91)

 
    

• G3 = 0.85 (0.65-1.11)

 
    

• G4 = 0.64 (0.55-0.73)

 

Leitzmann et al 2007 [198]

To examine PA guidelines in relation to mortality.

• n = 252,925 (142,828 male; 110,097 women)

Baseline and 6 month follow-up

• 7,900 deaths

Following PA guidelines is associated with lower risk of death. Mortality benefit may also be achieved by engaging in less than recommended activity levels.

USA

 

• Sex: Men and women

PA assessment: Questionnaire for MPA and VPA, 5 groups each MPA (h/wk)

Multivariate adjusted RR (95% CI) according to activity

 
  

• Age: 50-71 yr

 

MPA

 

Prospective cohort

 

• Characteristics: Participants free of CVD, cancer or emphysema

 

• G1 = 1.00 (referent)

 
  

• The National Institute of Health-American Association of Retired Persons

 

• G2 = 0.85 (0.79-0.93)

 
    

• G3 = 0.79 (0.74-0.85)

 

D & B score = 13

  

G1 = sedentary

• G4 = 0.76 (0.71-0.82)

 
   

G2 = <1

• G5 = 0.68 (0.63-0.74)

 
   

G3 = 1-3

Trend p = <0.001

 
   

G4 = 4-7

VPA

 
   

G5 = >7

  
   

VPA (frequency/wk)

• G1 = 1.00 (referent)

 
   

G1 = inactive

• G2 = 0.77(0.71-0.83)

 
   

G2 = <1

• G3 = 0.77 (0.72-0.82)

 
   

G3 = 1-2

• G4 = 0.68 (0.63-0.73)

 
   

G4 = 3-4

• G5 = 0.71 (0.66-0.77)

 
   

G5 = ≥ 5

Trend p = <0.001

 
   

Cox proportional HR

  

Leon et al 1997 [199]

To examine the long-term association of LTPA and risk of death from coronary heart disease and all-causes.

• n = 12,138

16 year follow-up

• 1,904 deaths

The data suggest that a relatively small amount of daily moderate intensity LTPA can reduce premature mortality in middle-aged and older men at high risk for CHD.

  

• Sex: Men

   
  

• Age: 35-57 yr

PA assessment: Minnesota LTPA questionnaire, categorized by frequency/month and average duration, deciles (min/d)

Multivariate adjusted RR (95% CI) by deciles of LTPA

 

USA

 

• Characteristics: Men who at entry to the study were free of clinical evidence of CHD or other serious medical problems but were at the upper 10%-15% of a CHD probability score distribution derived from the FHS data

   

Prospective cohort

   

• D1 = 1.00 (referent)

 
    

• D2-4 = 0.85 (0.73-0.99)

 
    

• D5-7 = 0.87 (0.75-1.02)

 

D & B score = 12

   

• D8-10 = 0.83 (0.71-0.97)

 
   

D1 = 4.9

  
   

D2-4 = 22.7

  
   

D5-7 = 53.9

  
   

D8-10 = 140.4

  
  

• Multiple Risk Factor Intervention Trial

Cox proportional HR

  

Lissner et al 1996 [200]

To examine the relationship of OPA and LTPA on all-cause mortality in women.

• n = 1,405

Baseline and 20 year follow-up

• 277 deaths

Decreases in PA as well as low initial levels are strong risk factors for mortality.

  

• Sex: Women

   
  

• Age: 38-60 yr

 

RR (95% CI) by LTPA

 

Sweden

 

• Characteristics: Free from major disease at baseline

PA assessment: Questionnaire for OPA and LTPA, 3 groups

  
    

20 year follow-up

 

Prospective cohort

   

LTPA during age 20-38 years

 
  

• The Gothenburg Prospective Study of Women

 

• Low = 1.00 (referent)

 
   

G1 = Low

• Med = 0.66 (0.34-1.26)

 

D & B score = 10

  

G2 = Medium

• High = 0.46 (0.21-1.01)

 
   

G3 = High

  
    

LTPA during age 39-60 years

 
   

Proportional hazard regression

• Low = 1.00 (referent)

 
    

• Med = 0.56 (0.35-0.90)

 
    

• High = 0.44 (0.22-0.91)

 
    

LTPA during the past 12 months

 
    

• Low = 1.00 (referent)

 
    

• Med = 0.56 (0.39-0.82)

 
    

• High = 0.45 (0.24-0.86)

 
    

20 year follow-up

 
    

OPA during age 20-38 years

 
    

• Low = 1.00 (referent)

 
    

• Med = 0.59 (0.18-1.87)

 
    

• High = 0.50 (0.16-1.58)

 
    

OPA during age 39-60 years

 
    

• Low = 1.00 (referent)

 
    

• Med = 0.66 (0.21-2.08)

 
    

• High = 0.47 (0.14-1.52)

 
    

OPA during the past 12 months

 
    

• Low = 1.00 (referent)

 
    

• Med = 0.28 (0.17-0.46)

 
    

• High = 0.24 (0.14-0.43)

 

Manini et al 2006 [201]

To determine whether energy expenditure is associated with all-cause mortality in older adults.

• n = 302 (150 men; 152 women)

Mean follow-up of 6.15 years

• 55 deaths

Free-living activity EE was strongly associated with lower risk of mortality.

  

• Sex: Men and women

 

HR (95% CI) by tertiles of PA EE

 

USA

 

• Age: 70-82 yr

PA assessment: Questionnaire, divided into tertiles of PA EE (kcal/d)

  

Prospective cohort

 

• Characteristics: High-functioning community dwelling elders

 

Adjusted for age, sex, race and study site

 
   

T1 = <521

• T1 = 1.00 (referent)

 

D & B score = 13

  

T2 = 521-770

• T2 = 0.63 (0.29-1.18)

 
   

T3 = >770

• T3 = 0.37 (0.15-0.76)

 
    

Trend p = 0.009

 
    

Adjusted for age, sex, race, study site, weight, height, percent body fat and sleep duration

 
    

• T1 = 1.00 (referent)

 
    

• T2 = 0.57 (0.30-1.09)

 
    

• T3 = 0.31 (0.14-0.69)

 
    

Trend p = 0.004

 
    

Adjusted for age, sex, race, study site, self rated health, education, smoking, CVD, lung disease, diabetes, hip or knee osteoarthritis, osteoporosis, cancer and depression

 
    

• T1 = 1.00 (referent)

 
    

• T2 = 0.65 (0.33-1.28)

 
    

• T3 = 0.33 (0.15-0.74)

 
    

Trend p = 0.007

 

Matthews et al 2007 [202]

To determine the effects of exercise and non-exercise PA on mortality.

• n = 67,143

Baseline and an average of 5.7 year follow-up

• 1,091 deaths

Overall PA levels are an important determinant of longevity.

  

• Sex: Women

   
  

• Age: 40-70 yr

 

RR (95% CI)

 

China

 

• Characteristics: Women without heart disease, stroke or cancer

   
   

PA assessment: Interview to report (MET h/d), 4 groups Overall activity

Multivariate adjustment

 

Prospective cohort

   

Overall activity (MET hr/d)

 
    

• G1 = 1.00 (referent)

 
  

• The Shanghai Women's Health Study

 

• G2 = 0.81 (0.69-0.96)

 

D & B score = 12

  

G1 = ≤ 9.9

• G3 = 0.67 (0.57-0.80)

 
   

G2 = 10.0-13.6

• G4 = 0.61 (0.51-0.73)

 
   

G3 = 13.7-18.0

Trend p = 0.000

 
   

G4 = ≥ 18.1

  
    

Adult exercise (MET hr/d)

 
   

Adult exercise

• G1 = 1.00 (referent)

 
   

G1 = 0

• G2 = 0.84 (0.74-0.96)

 
   

G2 = 0.1-3.4

• G3 = 0.77 (0.59-0.99)

 
   

G3 = 3.5-7.0

• G4 = 0.64 (0.36-1.14)

 
   

G4 = ≥ 7.1

Trend p = 0.008

 
   

Cox proportional hazard models

  

Menotti and Seccareccia 1985 [203]

To investigate the relationship between OPA and all-cause mortality.

• n = 99,029

Baseline and 5 year follow-up

• 2,661 deaths

The results suggest that PA may play a role in the prediction of fatal events.

  

• Sex: Men

   
  

• Age: 40-59 yr

   
  

• Characteristics: Men employed on the Italian railway system

PA assessment: Questionnaire Men at risk classified by 3 levels of PA and 3 levels of job responsibility, combined to create 8 groups of PA-job responsibility

Age adjusted death rates per 1000 over 5 years classified by PA only

 

Italy

   

• Sedentary = 26.20

 

Prospective cohort

   

• Moderate = 27.05

 
    

• Heavy = 27.35

 

D & B score = 12

   

Age adjusted death rates per 1,000 over 5 years classified by PA and job responsibility

 
   

G1 = sedentary -- low

• G1 = 30.00

 
   

G2 = sedentary -- med

• G2 = 25.20

 
   

G3 = sedentary -- high

• G3 = 25.80

 
   

G4 = moderate -- low

• G4 = 26.30

 
   

G5 = moderate -- med

• G5 = 28.50

 
   

G6 = moderate -- high

• G6 = 25.80

 
   

G7 = heavy -- low

• G7 = 26.90

 
   

G8 = heavy -- med

• G8 = 30.80

 

Mensink et al 1996 [204]

To compare various indices for PA and their association with cardiovascular risk factors as well as total and CVD mortality.

• n = 15,436 (7,689 men; 7797 women)

5-8 year follow-up

Incidence of all-cause mortality and PA

An inverse relation of PA and total mortality.

Germany

 

• Sex: Men and women

PA assessment: Questionnaire Total activity, 3 groups

Adjusted RR (95% CI)

 
  

• Age: 25-69 yr

   

Prospective cohort

 

• Characteristics: Participants from communities in Western Germany

 

Total activity, men

 
   

G1 = Low

• G1 = 1.00 (referent)

 
   

G2 = Moderate

• G2 = 0.56 (0.30-1.04)

 

D & B score = 12

  

G3 = High

• G3 = 0.78 (0.42-1.44)

 
    

Total activity, women

 
   

LTPA, 3 groups

• G1 = 1.00 (referent)

 
   

G1 = Low

• G2 = 1.24 (0.60-2.58)

 
   

G2 = Moderate

• G3 = 1.29 (0.58-2.85)

 
   

G3 = High

  
   

Conditioning activity, 3 groups

LTPA, men

 
    

• G1 = 1.00 (referent)

 
   

G1 = No activity

• G2 = 0.61 (0.35-1.05)

 
   

G2 = Moderate

• G3 = 0.79 (0.48-1.31)

 
   

G3 = High

LTPA, women

 
    

• G1 = 1.00 (referent)

 
   

Sports activity, 4 groups

• G2 = 0.94 (0.51-1.75)

 
    

• G3 = 0.81 (0.44-1.49)

 
   

G1 = no sports

  
   

G2 = <1 hour

Conditioning activity, men

 
   

G3 = 1-2 hours

• G1 = 1.00 (referent)

 
   

G4 = >2 hours

• G2 = 0.76 (0.44-1.34)

 
    

• G3 = 0.67 (0.36-1.25)

 
    

Conditioning activity, women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.38 (0.13-1.06)

 
    

• G3 = 0.80 (0.42-1.54)

 
    

Sports Activity, men

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.49 (0.26-0.95)

 
    

• G3 = 0.57 (0.30-1.09)

 
    

• G4 = 0.36 (0.16-0.79)

 
    

Sports activity, women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.38 (0.12-1.23)

 
    

• G3 = 0.52 (0.23-1.17)

 
    

• G4 = 0.28 (0.07-1.17)

 

Morgan and Clarke 1997 [205]

To assess the value of broadly based customary PA scores in predicting 10-year mortality in elderly people.

• n = 1,042 (407 men; 635 women)

10 year follow-up

Incidence of all-cause mortality and PA

A wide range of customary or habitual PA, can provide indices showing both cross sectional and predictive validity for 10 year mortality.

  

• Sex: Men and women

PA assessment: Questionnaire for PA, 3 groups

  

UK

 

• Age: ≥65 yr

 

HR (95% CI)

 
  

• Characteristics: British elders

 

Men

 

Prospective cohort

  

G1 = Low

• G1 = 1.59 (1.12-2.25)

 
  

• Nottingham Longitudinal Study of Activity and Aging

G2 = Intermediate

• G2 = 1.35 (0.96-1.89)

 
   

G3 = High

• G3 = 1.00 (referent)

 

D & B score = 12

   

Women

 
    

• G1 = 2.07 (1.53-2.79)

 
    

• G2 = 1.53 (1.12-2.09)

 
    

• G3 = 1.00 (referent)

 

Myers et al 2002 [206]

To compare PF and PA levels with all-cause mortality.

• n = 6,213

Baseline and mean 6.2 ± 3.7 year follow-up

• 1,256 deaths

Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CVD.

  

• Sex: Men

   
  

• Age: Mean 59 ± 11 yr

 

Age adjusted RR (95% CI) by quintile

 

USA

 

• Characteristics: Participants with a normal exercise test result (n = 2,534) and participants with an abnormal exercise test or CVD or both (n = 3,679)

   
   

PF assessment: Treadmill test for VO2 peak, divided into quintiles (METs)

• Q1 = 4.5 (3.0-6.8)

 

Prospective cohort

   

• Q2 = 2.4 (1.5-3.8)

 
    

• Q3 = 1.7 (1.1-2.8)

 
    

• Q4 = 1.3 (0.7-2.2)

 

D & B score = 12

  

Q1 = Lowest level

• Q5 = 1.00 (referent)

 
   

1.0-5.9

  
   

Q2

  
   

Q3

  
   

Q4

  
   

Q5 = Highest level

  
   

≥13.0

  

Ostbye et al 2002 [207]

To analyze the effect of smoking and other modifiable risk factors on ill health, defined in a multidimensional fashion.

• n = 12,956

6 year follow-up

• 782 deaths

Quitting smoking and increasing exercise levels are the lifestyle interventions most likely to improve overall health.

  

• Sex: Men and women

   
  

• Age: 50-60 yr

PA assessment: Questionnaire for PA, 4 groups

Incidence of all-cause mortality and PA

 

USA

 

• Characteristics: Participants from the Health and Retirement Study (HRS) only

   

Prospective cohort

  

G1 = Sedentary

Death rates (95% CI) per 1000 population/yr

 
   

G2 = Light

  
   

G3 = Moderate

• G1 = 20.6 (17.8-24.0)

 

D & B score = 13

  

G4 = Heavy

• G2 = 9.1 (8.1-9.5)

 
    

• G3 = 8.3 (7.5-9.2)

 
    

• G4 = 4.4 (3.5-5.6)

 

Paffenbarger et al 1994 [208]

To study the adoption or maintenance of PA and other optional lifestyle patterns for their influence on mortality rates of Harvard College alumni.

• n = 14,786

Follow-up between

• 2,343 deaths

Adopting a physically active lifeway delays mortality and extends longevity.

  

• Sex: Men

1977 and 1988

  
  

• Age: 45-84 yr (in 1977)

 

RR (95% CI) of mortality according to PA

 

USA

  

PA assessment: Questionnaire for blocks walked daily, stairs climbed daily and type, frequency and duration of weekly sports and recreational activities

  
  

Characteristics: Harvard College alumni

   

Prospective cohort

   

Physical activity index (kcal/wk)

 
    

• G1 = 1.00 (referent)

 

D & B score = 14

   

• G2 = 1.13 (1.01-1.26)

 
    

• G3 = 0.72 (0.64-0.82)

 
    

• G4 = 0.77 (0.69-0.85)

 
   

Physical activity index (kcal/wk) Sports and recreational activities were scored according to intensity and duration

Walking (km/wk)

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 1.21 (1.08-1.35)

 
    

• G3 = 0.94 (0.83-1.07)

 
    

• G4 = 0.89 (0.78-1.01)

 
    

Moderately vigorous sports play (METs)

 
   

Light < 4.5 METs

  
   

Moderate ≥ 4.5 METs

  
    

• G1 = 1.00 (referent)

 
    

• G2 = 1.11 (0.93-1.33)

 
    

• G3 = 0.73 (0.65-0.81)

 
    

• G4 = 0.72 (0.64-0.80)

 
    

Adjusted for potential confounding influences

 

Richardson et al 2004 [209]

To investigate the impact of a sedentary lifestyle on all-cause mortality.

• n = 9,611 (4,642 men; 4,969 women)

Baseline (1992) and 8 year follow-up

• 810 deaths

A sedentary lifestyle is associated with a higher risk of death in pre- retirement aged adults.

  

• Sex: Men and women

 

OR (95% CI)

 

USA

 

• Age: 51-61 yr

PA assessment: Questionnaire for PA, 3 groups:

• G1 = 1.00 (referent)

 

Prospective cohort

 

• Characteristics: Participants born between 1931-1941 and who not institutionalized in 1992

 

• G2 = 0.64 (0.52-0.81)

 
   

G1 = Sedentary

• G3 = 0.62 (0.44-0.85)

 
   

G2 = occasional or light

p = 0.01

 

D & B score = 13

  

G3 = Regular MVPA

  
  

• Health and Retirement Study

   

Rockhill et al 2001 [210]

To determine the association between recreational PA and mortality in women.

• n = 80,348

Baseline (1980) and follow-up between 1982-1996

• 4,871 deaths

People who are more physically active are at reduced mortality risk relative to those who are less active.

  

• Sex: Women

   
  

• Age: 30-55 yr

 

Multivariate adjusted RR (95% CI) by (hr/wk)

 

USA

 

• Characteristics: Free from CVD or cancer at baseline

   
  

• Nurses Health Study

PA assessment: Questionnaire in 1980 and up-dated every 2- 4 years, 5 groups of PA (hr/wk)

• G1 = 1.00 (referent)

 

Prospective cohort

   

• G2 = 0.82 (0.76-0.89)

 
    

• G3 = 0.75 (0.69-0.81)

 
    

• G4 = 0.74 (0.68-0.81)

 

D & B score = 11

   

• G5 = 0.71 (0.61-0.82)

 
    

p<0.001

 
   

G1 = <1

  
   

G2 = 1-1.9

  
   

G3 = 2-3.9

  
   

G4 = 4-6.9

  
   

G5 = ≥7

  

Rosengren and Wilhelmsen 1997 [211]

To investigate the effect of OPA and LTPA on risk of death.

• n = 7,142

Baseline (1970-1973) and 20 year follow-up

• 2,182 deaths

The study demonstrates the protective effect of LTPA on mortality.

  

• Sex: Men

   
  

• Age: 47-55 yr

 

Unadjusted RR (95% CI)

 
  

• Characteristics: Without symptomatic CHD

PA assessment: Postal questionnaires, 3 groups:

• G1 = 1.00 (referent)

 

Sweden

   

• G2 = 0.74 (0.68-0.82)

 
    

• G3 = 0.73 (0.68-0.79)

 

Prospective cohort

  

G1 = Sedentary

  
   

G2 = Moderately active

Multivariate adjustment

 
   

G3 = Regular exercise

• G1 = 1.00 (referent)

 

D & B score = 13

   

• G2 = 0.84 (0.77-0.93)

 
    

• G3 = 0.83 (0.77-0.90)

 

Schnohr et al 2003 [212]

To assess the associations of regular LTPA and changes in LTPA with risk of death.

• n = 7,023 (4,471 men; 5,676 women)

18 year follow-up

• 2,725 deaths

Maintaining or adopting a moderate or high degree of PA was associated with lower risk of death.

  

• Sex: Men and women

PA assessment: Questionnaire, 9 groups

Incidence of all-cause mortality and PA and changes in PA

 

Denmark

 

• Age: 20-79 yr

   
  

• Characteristics: Participants from the Copenhagen City Heart Registered Population

   

Prospective cohort

  

G1 = Low--low

  
   

G2 = Low--moderate

Adjusted RR (95% CI)

 
   

G3 = Low--high

Men

 

D & B score = 12

  

G4 = Moderate- low

• G1 = 1.00 (referent)

 
   

G5 = Moderate-Moderate

• G2 = 0.64 (0.49-0.83)

 
    

• G3 = 0.64 (0.47-0.87)

 
   

G6 = Moderate-high

• G4 = 0.73 (0.56-0.96)

 
   

G7 = High-low

• G5 = 0.71 (0.57-0.88)

 
   

G8 = High-moderate

• G6 = 0.64 (0.51-0.81)

 
   

G9 = High-high

• G7 = 1.11 (0.76-1.62)

 
    

• G8 = 0.66 (0.51-0.85)

 
    

• G9 = 0.61 (0.48-0.76)

 
    

Women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.75 (0.57-0.97)

 
    

• G3 = 0.72 (0.50-1.05)

 
    

• G4 = 0.70 (0.54-0.91)

 
    

• G5 = 0.64 (0.52-0.79)

 
    

• G6 = 0.58 (0.45-0.73)

 
    

• G7 = 0.72 (0.48-1.07)

 
    

• G8 = 0.61 (0.47-0.80)

 
    

• G9 = 0.66 (0.51-0.85)

 

Schnohr et al 2004 [213]

To examine whether the relationship between established risk factors and mortality differs with socioeconomic status as measured by level of education.

• n = 30,635 (16,236 men; 14,399 women)

16 year follow-up

• 10,952 deaths

The study shows the strong predictive effect of PA on mortality is independent of education level.

  

• Sex: Men and women

Socioeconomic status assessment: level of education

Incidence of all-cause mortality and PA stratified by years of education

 

Denmark

 

• Age: 20-93 yr

   
  

• Characteristics: Participants from the Copenhagen City Heart Registered Population

   

Prospective cohort

  

PA assessment: Questionnaire

Deaths <8 years of education

 

D & B score = 12

   

Men

 
   

4 groups of PA

G1 = 916

 
   

G1 = none or very little

G2 = 1693

 
   

G2 = 2-4 h/wk of LPA

G3 = 1012

 
   

G3 = >4 h/wk of LPA or 2-4 h/wk of high level activity

G4 = 67

 
   

G4 = Competition level or >4 h/wk of hard level activity

Women

 
    

• G1 = 872

 
    

• G2 = 1298

 
    

• G3 = 346

 
    

• G4 = 10

 
    

8-11 years of education

 
    

Men

 
    

• G1 = 432

 
    

• G2 = 1040

 
    

• G3 = 616

 
    

• G4 = 33

 
    

Women

 
    

• G1 = 363

 
    

• G2 = 852

 
    

• G3 = 268

 
    

• G4 = 10

 
    

>11 years of education

 
    

Men

 
    

• G1 = 104

 
    

• G2 = 302

 
    

• G3 = 182

 
    

• G4 = 11

 
    

Women

 
    

• G1 = 48

 
    

• G2 = 129

 
    

• G3 = 61

 
    

• G4 = 3

 

Schnohr et al 2006 [214]

To investigate the association between LTPA and mortality.

• n = 4,894 (2,136 men; 2,758 women)

Baseline (1976) and start of follow-up in 1981-1983 (to 2000)

• 1,787 deaths

Long-term moderate or high PA was associated with significantly lower mortality in men and women.

  

• Sex: Men and women

 

RR (95% CI)

 

Denmark

 

• Age: 20-79 yr

   
  

• Characteristics: Healthy males and women

 

Unadjusted

 

Prospective cohort

  

PA assessment: Survey for LTPA, 3 groups:

• G1 = 1.00 (referent)

 
    

• G2 = 0.64 (0.56-0.73)

 
  

• The Copenhagen City Heart Study

 

• G3 = 0.56 (0.48-0.65)

 

D & B score = 13

  

G1 = Low

Trend p < 0.001

 
   

G2 = Mod

  
   

G3 = High

Multivariate adjustment

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.78 (0.68-0.89)

 
    

• G3 = 0.75 (0.64-0.87)

 
    

Trend p = 0.001

 

Schooling et al 2006 [215]

To examine how a Comprehensive assessment of baseline health status affects the relationship between obesity or PA and mortality.

• n = 54,088 (17,849 men; 36,239 women)

4.1 year follow-up

• 3,819 deaths

PA, which normally has a negative relationship with adiposity, had the largest impact on survival for the health states, with the strongest inverse relationship between BMI and mortality.

  

• Sex: Men and women

PA assessment: Interview for PA min/d, 3 groups

Incidence of all-cause mortality and PA

 

Hong Kong

 

• Age: ≥ 65 yr

   

Prospective cohort

 

• Characteristics: Chinese elders

G1 = None

Adjusted HR (95% CI)

 
   

G2 = ≤ 30 min/d

• G1 = 1.00 (referent)

 
   

G3 = ≥ 30 min/d

• G2 = 0.83 (0.76-0.91)

 

D & B score = 13

   

• G3 = 0.73 (0.67-0.80)

 
    

Trend p<0.001

 

Sundquist et al 2004 [216]

To study the association between varying levels of PA and all-cause mortality in the elderly.

• n = 3,206 (1,414 men; 1,792 women)

Baseline (1988-1989) and follow-up in 2000

• 1,806 deaths

Even occasional PA decreases the risk of mortality among elderly people.

  

• Sex: Men and women

PA assessment: Questionnaire for PA, 5 groups

Age-adjusted HR (95% CI)

 

Sweden

 

• Age: ≥65 yr

 

Men

 
  

• Characteristics: Non-institutionalized elders

 

• G1 = 1.00 (referent)

 

Prospective cohort

   

• G2 = 0.74 (0.62-0.87)

 
   

G1 = none

• G3 = 0.57 (0.44-0.73)

 
  

The Swedish Annual Level-of-Living Survey (Statistics Sweden)

G2 = occasionally

• G4 = 0.51 (0.41-0.64)

 

D & B score = 12

  

G3 = once per week

• G5 = 0.60 (0.44-0.82)

 
   

G4 = twice per week

Women

 
   

G5 = vigorously at least twice per week

• G1 = 1.00 (referent)

 
    

• G2 = 0.70 (0.59-0.82)

 
    

• G3 = 0.59 (0.46-0.77)

 
   

Cox proportional HR

• G4 = 0.47 (0.35-0.62)

 
    

• G5 = 0.54 (0.31-0.94)

 
    

Men and women

 
    

Multivariate adjustment

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.72 (0.64-0.81)

 
    

• G3 = 0.60 (0.50-0.71)

 
    

• G4 = 0.50 (0.42-0.59)

 
    

• G5 = 0.60 (0.46-0.79)

 

Talbot et al 2007 [217]

To investigate how changes in LTPA affect all-cause mortality.

• n = 2,092 (1,316 men; 776 women)

Baseline in 1958 for males and in 1978 for females and an average follow-up of 21.2 ± 9.4 years for men and 10.2 ± 5.6 years for women

• 628 deaths (538 male; 90 female)

Greater declines in total and high-intensity LTPA are independent predictors of all-cause mortality.

  

• Sex: Men and women

   

USA

 

• Age: 19-<90 yr

 

RR (95% CI) for standard deviation of rate of change in LTPA

 

Prospective cohort

 

• Characteristics: Community residents, generally with above average income, high education and with good or excellent self related health

 

(If RR is <1 then a SD increase is associated with decrease mortality. If RR is >1, then a SD increase is associated with increase in mortality)

 

D & B score = 13

  

PA assessment: Questionnaire for LTPA (METs min/24 h), 3 groups

  
  

The Baltimore Longitudinal Study of Aging

G1 = low

  
   

G2 = medium

Multivariate adjustment

 
   

G3 = high

Men <70 years

 
   

Rate of change (ROC)

• G1 = 0.96 (0.84-1.08)

 
    

• G2 = 0.91 (0.79-1.04)

 
    

• G3 = 0.42 (0.33-0.53)

 
    

• ROC low = 0.90 (0.80-1.01)

 
    

• ROC med = 1.01 (0.90-1.14)

 
    

• ROC high = 0.78 (0.65-0.94)

 
    

Men >70 years

 
    

• G1 = 0.95 (0.82-1.10)

 
    

• G2 = 0.89 (0.76-1.05)

 
    

• G3 = 0.78 (0.62-0.97)

 
    

• ROC low = 1.07 (0.93-1.24)

 
    

• ROC med = 1.13 (1.00-1.27)

 
    

• ROC high = 0.91 (0.75-1.12)

 
    

Women <70 years

 
    

• G1 = 0.75 (0.53-1.07)

 
    

• G2 = 0.61 (0.36-1.03)

 
    

• G3 = 0.80 (0.50-1.30)

 
    

• ROC low = 1.02 (0.74-1.40)

 
    

• ROC med = 1.38 (0.86-2.28)

 
    

• ROC high = 0.90 (0.63-1.27)

 
    

Women >70 years

 
    

• G1 = 0.85 (0.63-1.15)

 
    

• G2 = 0.78 (0.39-1.59)

 
    

• G3 = 0.62 (0.32-1.22)

 
    

• ROC low = 1.10 (0.85-1.42)

 
    

• ROC med = 0.96 (0.46-2.03)

 
    

• ROC high = 0.70 (0.40-1.22)

 

Trolle-Lagerros et al 2005 [218]

To quantify the effect of PA on overall mortality in younger women and to assess the effect of past versus current activity.

• n = 99,099

11.4 year follow-up

• 1,313 deaths

Current PA substantially reduces mortality among women. The association is observed even with low levels of PA and is accentuated with increased PA.

  

• Sex: Women

   
  

• Age: 30-49 yr

PA assessment: Questionnaire using a 5 point scale, 5 groups

Incidence of all-cause mortality and PA past and current

 

Sweden and Norway

 

• Characteristics: Participants from Norway and one region of Sweden

   

Retrospective cohort

  

G1 = Sedentary

Adjusted HR (95% CI)

 
   

G2 = Low

PA at enrolment

 
   

G3 = Moderate

• G1 = 1.00 (referent)

 

D & B score = 13

  

G4 = High

• G2 = 0.78 (0.61-1.00)

 
   

G5 = Vigorous

• G3 = 0.62 (0.49-0.78)

 
    

• G4 = 0.58 (0.44-0.75)

 
    

• G5 = 0.46 (0.33-0.65)

 
    

Trend p<0.0001

 
    

PA at age 30 yr

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.79 (0.55-1.15)

 
    

• G3 = 0.90 (0.64-1.28)

 
    

• G4 = 0.98 (0.68-1.42)

 
    

• G5 = 0.96 (0.65-1.44)

 
    

Trend p = 0.22

 
    

PA at age 14 yr

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.95 (0.66-1.38)

 
    

• G3 = 0.96 (0.69-1.34)

 
    

• G4 = 0.88 (0.62-1.25)

 
    

• G5 = 1.06 (0.75-1.51)

 
    

Trend p = 0.62

 

Villeneuve et al 1998 [219]

To examine the relationship between PF, PA and all-cause mortality.

• n = 14,442 (6,246 men; 8,196 women)

Baseline (1981) and 7 year follow-up

RR (95% CI) by EE, multivariate adjustment

There was a reduction in mortality risk associated with even modest participation in activities of low intensity.

  

• Sex: Men and women

   

Canada

 

• Age: 20-69 yr

PA assessment: Questionnaire for EE (kcal/kg/day), 5 groups

LTPA, men

 
  

• Characteristics: Asymptomatic for CVD

 

• G1 = 1.00 (referent)

 

Prospective cohort

   

• G2 = 0.81 (0.59-1.11)

 
    

• G3 = 0.79 (0.54-1.13)

 
  

Canadian Fitness Survey

G1 = 0-<0.5

• G4 = 0.86 (0.61-1.22)

 

D & B score = 11

  

G2 = 0.5-<1.5

• G5 = 0.82 (0.65-1.04)*

 
   

G3 = 1.5-<3.0

  
   

G4 = ≥ 3.0

Non vigorous LTPA, men

 
   

G5 = ≥ 0.5

• G1 = 1.00 (referent)

 
   

PF levels:

• G2 = 0.81 (0.56-1.17)

 
   

Recommended

• G3 = 0.70 (0.44-1.13)

 
   

Minimum

• G4 = 0.82 (0.53-1.27)

 
    

• G5 = 0.78 (0.59-1.04)*

 
   

Undesirable Refusal

  
    

LTPA, women

 
   

Multivariate Poisson regression analysis

• G1 = 1.00 (referent)

 
    

• G2 = 0.94 (0.69-1.30)

 
    

• G3 = 0.92 (0.64-1.34)

 
    

• G4 = 0.71 (0.45-1.11)

 
    

• G5 = 0.88 (0.68-1.04)*

 
    

Non vigorous LTPA, women

 
    

• G1 = 1.00 (referent)

 
    

• G2 = 0.97 (0.69-1.36)

 
    

• G3 = 0.87 (0.57-1.33)

 
    

• G4 = 0.72 (0.43-1.21)

 
    

• G5 = 0.89 (0.67-1.17)*

 
    

RR (95% CI) by fitness levels, adjusted for age, sex and smoking Recommended = 1.00 (referent)

 
    

• Minimum = 1.02 (0.69-1.51)

 
    

• Undesirable = 1.52 (0.72-3.18)

 
    

• Refusal = 1.04 (0.45-2.39)

 

Weller and Corey 1998 [220]

To study the relationship between PA and mortality in women.

• n = 6,620

Baseline and 7 year follow-up

• 449 deaths

PA is inversely associated with risk of death in women.

  

• Sex: Women

   
  

• Age: ≥;30 yr

 

OR (95% CI)

 

Canada

 

• Characteristics: Without known heart disease

PA assessment: Questionnaires for: EE (kcal/kg/d), quartiles

  
  

• Canadian Fitness Survey

 

EE (kcal/kg/d)

 

Prospective cohort

   

• Q1 = 1.00 (referent)

 
    

• Q2 = 0.91 (0.66-1.25)

 
   

Q1 = lowest

• Q3 = 0.94 (0.72-1.23)

 

D & B score = 11

  

Q2 =

• Q4 = 0.89 (0.67-1.17)

 
   

Q3 =

  
   

Q4 = highest

LTPA levels

 
   

LTPA, 3 groups

• G1 = 1.00 (referent)

 
   

G1 = Sedentary

• G2 = 0.63 (0.46-0.86)

 
   

G2 = Mod

• G3 = 0.76 (0.59-0.98)

 
   

G3 = High

  
    

Walking

 
   

Walking, 3 groups

• G1 = 1.00 (referent)

 
   

G1 = < half the time

• G2 = 0.64 (0.49-0.82)

 
   

G2 = half the time

• G3 = 0.64 (0.47-0.86)

 
   

G3 = > half the time

  

Yu et al 2003 [221]

To examine the relationship between LTPA and all-cause mortality.

• n = 1,975

Baseline and 10 year follow-up

• 252 deaths

The study found a strong inverse association between heavy LTPA and all-cause mortality.

UK

 

• Sex: Men

   
  

• Age: 49-64 yr

 

Age adjusted HR (95% CI)

 
  

• Characteristics: Without a history of CHD at baseline

PA assessment: Questionnaire (Minnesota LTPA index, kcal/d), 3 group

• G1 = 1.00 (referent)

 
    

• G2 = 0.73 (0.54-0.99)

 

Prospective cohort

   

• G3 = 0.74 (0.55-1.04)

 
    

Trend p = 0.046

 

D & B score = 11

  

G1 = Light to no activity

Multivariate adjusted

 
   

G2 = Moderate activity

• G1 = 1.00 (referent)

 
   

G3 = Heavy activity

• G2 = 0.79 (0.58-1.08)

 
    

• G3 = 0.76 (0.56-1.04)

 
    

Trend p = 0.083

 

D & B score, Downs and Black quality score; PF, physical fitness; YR, years; RR, risk ratio; 95% CI, 95% confidence interval; PA, physical activity; VO2 peak, peak oxygen consumption; HR, hazard ratio; min/d, minutes per day; kcal/wk, kilocalories per week; LTPA, leisure-time physical activity; MET, metabolic equivalent; VO2 max, maximal oxygen consumption; OPA, occupational physical activity; CVD, cardiovascular disease; hr/wk, hours per week; MPA, moderate physical activity; kcal/kg/wk, kilocalories per kilogram per week; kJ/wk, kilojoules per week; EE, energy expenditure; G, groups; EE, energy expenditure; BMI, body mass index; C, class; kg/m2, kilogram by meters squared; HR, heart rate; BPM, beats per minute; MVPA, moderate to vigorous physical activity; OR, odds ratio; Q, quartile or quintile; RCT, randomized clinical trial; T, tertiles; TPA, total physical activity; VPA, vigorous physical activity; mL/kg/min, milliliters per kilogram per minute.

We observed a mean 31% lower risk for all-cause mortality in the most active individuals. The median risk reduction was 32%. It is important to highlight that many of these studies included women, with sub-analyses that revealed similar risk reductions between sexes. Our findings are consistent with previous reports [15, 16, 2931]. The majority (90%) of the studies supported the health benefits of physical activity demonstrating a significant risk reduction in physically active individuals. The level of evidence would be considered to be a Level 2A based on the presence of overwhelming evidence from observational trials. The studies examined were generally of a good quality with a mean (and median) score of 12 out of 15 (range 10-14).

A clear dose-response relationship was also observed with marked reductions in the risk for all-cause mortality occurring with relatively small increments in physical activity (Figure 3). To examine more closely the temporal relationship between physical activity and all-cause mortality we calculated the (unadjusted) relative risks associated with incremental levels of physical activity/fitness using the reported cases of all-cause mortality and the number of participants (per group) in each investigation. In some instances, we were required to calculate the number of participants based on the reported incidence rates and person years, or based on data obtained directly from the authors (2 investigations). We were not able to obtain this information in 18 investigations, and as such this analysis was restricted to the remaining 52 investigations. There was considerable variability in the methods of classifying the physical activity/fitness levels of the participants. Accordingly, Figure 3 illustrates the mean relative risk reduction according to three separate study types including those that subdivided participants into tertiles, quartiles and quintiles, respectively. This figure demonstrates clearly the dose-response relationship between physical activity and all-cause mortality. Collectively, the literature is consistent indicating that the current Canadian guidelines (approximately 4.2 MJ/wk, 1000 kcal/wk) are associated with a 20-30% lower risk for premature all-cause mortality, with greater health benefits with high volumes and/or intensities of activity. In our analyses it was apparent that the greatest differences in risk occurred between the lowest adjacent activity/fitness categories, suggesting that sedentary individuals can markedly reduce their risk for all-cause mortality with relatively minor increments in physical activity. This is consistent with the current messaging of Canada's physical activity guidelines.
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Figure 3

Mean relative risk reduction in all-cause mortality across physical activity/fitness categories.

The strength of the relationship between physical fitness and premature mortality has been well-established [6, 32, 33]. In our analyses there were greater risk reductions in studies that took objective measures of physical fitness. We observed an average risk reduction of approximately 45%, which was consistent between men and women. A risk reduction of greater than 50% was not uncommon in these studies. For instance, Myers et al. (2004) reported that being fit or physically active was associated with greater than 50% lower mortality risk in men. They also noted that a 4.2 MJ/wk (1000 kcal/wk) increase in physical activity, or a 1 metabolic equivalent (MET) higher physical fitness level was associated with a mortality benefit of around 20%. It is also important to highlight that longitudinal studies evaluating changes in physical activity or fitness have revealed a lower premature mortality risk [16, 3441]. As we previously reported, routine physical activity or elevated physical fitness also appears to reduce the risk for premature mortality in individuals with risk factors for chronic disease [42, 43].

Implications

Since the seminal work of Morris and colleagues (in the 1950s [44, 45]) and the early work of Paffenbarger (in the 1970s [46, 47]) there has been considerable research (especially epidemiological evidence) documenting the health benefits of engaging in routine physical activity and/or being physically fit [17, 48]. Both physical activity (a behaviour) and physical fitness (an attained state) appear to be related to health status in a dose-dependent fashion, with physical fitness demonstrating the strongest relationship [18, 19]. Numerous reports indicate that physical inactivity and/or low physical fitness are associated with an increased risk for chronic disease and premature all-cause and disease-specific mortality [2, 43, 4951]. Some of the most compelling research includes the relationship between physical activity/fitness and all-cause mortality. As demonstrated below and in Table 11 and Figure 1, this literature is extensive.

The assessment of the relationship between all-cause mortality is complicated by the inclusion of deaths related to suicides, homicide, and accidents [18, 19, 52]. Nonetheless, the available evidence is incontrovertible; individuals who are habitually physically active and/or physically fit are at a markedly reduced risk for premature all-cause mortality [15, 16, 18, 19]. In Canada, physical inactivity is a major cause of premature mortality from diseases of the cardiovascular system (33.3%), cancers (29.1%), and type 2 diabetes (3.5%) [53]. Globally, physical inactivity has been linked with 2 million premature deaths per year, including 22% of cases of coronary heart disease, and 10-16% of cases of breast cancer, colon cancer, rectal cancer and type 2 diabetes [54]. As such, the promotion of the health benefits of physical activity is of paramount importance for the effective prevention of chronic disease and premature mortality on a national and international scale.

In summary, there is a clear dose-response relationship between physical activity and premature all-cause mortality. Physically active individuals have an approximate risk reduction of 31% in comparison to physically inactive individuals. When objective measures of aerobic fitness are taken the risk reductions are even greater approximating 45%.

Recommendation #1

For a reduced risk for premature mortality, it is recommended that individuals should participate in 30 min or more of moderate to vigorous exercise on most days of the week. Greater health benefits appear to occur with higher volumes and/or intensities of activity. [Level 2, Grade A]

Primary Prevention of Cardiovascular Disease

In our systematic search of the literature, a total of 9408 citations were identified during the electronic database search (Figure 4). Of these citations, 5973 were identified in MEDLINE, 2561 in EMBASE, 193 in Cochrane, and 681 in the CINAHL/SportDiscus/PsychInfo search. A total of 923 duplicates were found, leaving a total of 8485 unique citations. A total of 8138 articles were excluded after scanning, leaving a total of 347 articles for full review. An additional 20 articles were added through cross-referencing. From these articles 319 were excluded after full review leaving 33 articles for inclusion in the systematic review. The reasons for exclusion included non-experimental studies (n = 45), only effect on cardiovascular disease risk factors (n = 115), did not report 3 levels of physical activity (n = 12), subjects less than 18 yr of age (n = 4), reviews, summaries, dissertations, thesis, and abstracts (n = 30), clinical population (n = 14), not on cardiovascular disease or did not fit definition of cardiovascular disease (n = 78), and other (n = 19). Therefore, a total of 49 articles were included in the systematic review of the literature regarding the relationship between physical activity and the incidence of cardiovascular disease.
https://static-content.springer.com/image/art%3A10.1186%2F1479-5868-7-39/MediaObjects/12966_2009_Article_345_Fig4_HTML.jpg
Figure 4

Results of the Literature Search for Cardiovascular Disease.

The majority of the studies included in our systematic review were prospective cohort investigations (Table 12). These studies involved a total of 726,474 participants; averaging 12,313 participants per study (range 680-88,393). There were a total of 34,815 reported cases of cardiovascular disease (ranging per study from 42-2,596). The total length of study follow-up for the prospective cohort studies averaged 14.1 yr (ranging from 2-29 yr). The articles were published over a 32 yr period ranging from 1975 to 2007. These studies involved large samples of men and women from regions throughout the world.
Table 12

Studies examining the relationship between physical activity and cardiovascular disease.

Publication Country Study Design Quality Score

Objective

Population

Methods

Outcome

Comments and Conclusions

Paffenbarger and Hale 1975 [47]

To evaluate the role of PA in reducing coronary mortality among longshoreman

• n = 6,351

22 years of follow up, or until reached the age of 75 yr

RR (95% CI) Sudden death

VPA is associated with reduced risk of coronary mortality, particularly sudden cardiac death.

USA

 

• Sex: Men

 

   • G1 = 1.00 (referent)

 
  

• Age: 35-74 yr

 

   • G2 = 3.5

 
  

• Characteristics: Longshoreman

PA assessment: Energy and oxygen cost requirements of longshoring jobs

   • G3 = 2.8

 

Prospective cohort

   

Delayed death

 
    

   • G1 = 1.00 (referent)

 

D & B score = 12

   

   • G2 = 1.4

 
   

Activity level

   • G3 = 1.5

 
   

G1 = Heavy (5.2-7.5 kcal/min)

Unspecified death

 
   

G2 = Moderate (2.4-5.0 kcal/min)

   • G1 = 1.00 (referent)

 
   

G3 = Light (1.5-2.0 kcal/min)

   • G2 = 1.1

 
    

   • G3 = 1.6

 
   

Outcome measure: Death from CHD

  

Manson et al 2002 [56]

To compare the roles of walking and vigorous exercise in the prevention of CV events in a large, ethnically diverse cohort of postmenopausal women.

• n = 73,743

Enrolment from 1994-98 Clinic visit for baseline screening,

   • Number of New Cases: 345

Both walking and VPA are associated with substantial reductions in the incidence of CHD events.

USA

 

• Sex: Women

 

   • Total Number of CVD events: 1551

 
  

• Age: 50-79 yr

   
  

• Characteristics: Healthy, Post Menopausal

 

Age adjusted RR (95% CI) Total exercise (MET-hr/wk)

 
   

PA assessment: Questionnaire for: Total exercise (MET- hr/wk)

  

Prospective cohort

  

G1 = 0-2.4

   • G1 = 1.00 (referent)

 
  

• Women's Health Initiative Observational Study

G2 = 2.5-7.2

   • G2 = 0.73 (0.53-0.99)

 
   

G3 = 7.3-13.4

   • G3 = 0.69 (0.51-0.95)

 

D & B score = 12

  

G4 = 13.5-23.3

   • G4 = 0.68 (0.50-0.93)

 
   

G5 = ≥ 23.4

   • G5 = 0.47 (0.33-0.67)

 
    

p = <0.001

 
    

Walking (MET-hr/wk)

 
   

Walking (MET-hr/wk)

   • G1 = 1.00 (referent)

 
   

G1 = None

   • G2 = 0.71 (0.53-0.96)

 
   

G2 = 0.1-2.5

   • G3 = 0.60 (0.44-0.83)

 
   

G3 = 2.6-5.0

   • G4 = 0.54 (0.39-0.76)

 
   

G4 = 5.1-10.0

   • G5 = 0.61 (0.44-0.84)

 
   

G5 > 10

p = 0.004

 
   

Time for VPA (min)

Vigorous exercise

 
   

G1 = None

   • G1 = 1.00 (referent)

 
   

G2 = 1-60

   • G2 = 1.12 (0.79-1.60)

 
   

G3 = 61-100

   • G3 = 0.56 (0.32-0.98)

 
   

G4 = 101-150

   • G4 = 0.73 (0.43-1.25)

 
   

G5 = >150

   • G5 = 0.58 (0.34-0.99)

 
    

p = 0.008

 
   

Outcome Measure: Incidence of CVD and CHD

  

Wisloff et al 2006 [58]

To study the association between the amount and intensity of exercise and CVD mortality.

• n = 56,072 (27,143 men; 28,929 women)

Length of follow-up: 16 ± 4 yr

   • Number of Cases: 1,603 male, 993 female

Men and women who exercise to a moderate degree and spend less than the recommended energy (< 1000 kcal/wk) are at lower risk of dying from heart disease than those who never exercise.

Norway

 

• Sex: Men and women

PA assessment: Questionnaire for LTPA, 4 groups

Multivariate RR (95% CI)

 

Prospective cohort

 

• Age: ≥ 20 yr

 

Men

 
  

• Characteristics: Free form CVD

Men

   • Q1 = 1.00 (referent)

 
   

Q1 = None

   • Q2 = 0.66 (0.50-0.87)

 

D & B score = 12

 

• HUNT study

Q2 = 1/wk >30 min high

   • Q3 = 0.83 (0.65-1.06)

 
   

Q3 = 2-3/wk > 30 min high

   • Q4 = 0.77 (0.59-1.01)

 
   

Q4 = ≥ 4/wk > 30 min high

Women

 
    

   • Q1 = 1.00 (referent)

 
   

Women

   • Q2 = 0.63 (0.31-1.29)

 
   

Q1 = None

   • Q3 = 0.66 (0.32-1.34)

 
   

Q2 = 1/wk ≤ 30 min low

   • Q4 = 0.86 (0.45-1.62)

 
   

Q3 = 1/wk ≤ 30 min high

  
   

Q4 = 2-3/wk ≤ 30 min low

  
   

Outcome Measure: Ischaemic heart disease mortality

  
   

Cox proportional HR

  

Lee et al 2001 [59]

To examine the relationship between PA (specifically walking) and CHD among women, including those at high risk for CHD.

• n = 39,372

Recruitment of Participants: Sept 1992-May 1995

   • Number of Cases: 244

Even light to moderate activity is associated with lower CHD rates in women.

USA and Puerto Rico

 

• Sex: Women

   
  

• Age: ≥ 45 yr

 

Multivariate RR (95% CI) Time spent walking

 
  

• Characteristics: Healthy

PA assessment: Questionnaires Divided into 4 or 5 groups:

   • G1 = 1.00 (referent)

 
  

• Women's Health Study

 

   • G2 = 0.86 (0.57-1.29)

As little as 1 hour of walking per week predicted lower risk.

Prospective cohort

   

   • G3 = 0.49 (0.28-0.86)

 
    

   • G4 = 0.48 (0.29-0.78)

 
    

p = <0.001

 

D & B score = 12

  

Time spent walking

  
   

G1 = No regular walking

Walking pace

 
   

G2 = 1-59 min/wk

   • G1 = 1.00 (referent)

 
   

G3 = 1.0-1.5 h/wk

   • G2 = 0.56 (0.32-0.97)

 
   

G4 = ≥ 2.0 h/wk

   • G3 = 0.71 (0.47-1.05)

 
   

Walking pace (km/h)

   • G4 = 0.52 (0.30-0.90)

 
   

G1 = No regular walking

p = 0.02

 
   

G2 = 3.2

  
   

G3 = 3.2-4.7

  
   

G4 = ≥ 4.8

EE (kcal/wk)

 
    

   • Q1 = 1.00 (referent)

 
   

EE (kcal/wk)

   • Q2 = 0.79 (0.56-1.12)

 
   

G1 = 200

   • Q3 = 0.55 (0.37-0.82)

 
   

G2 = 200-599

   • Q4 = 0.75 (0.50-1.12)

 
   

G3 = 600-1499 and

p = 0.03

 
   

G4 = 1500 or more

  
    

Energy expended VPA (kcal/wk)

 
   

Energy expenditure for VPA (kcal/wk)

   • G1 = 1.00 (referent)

 
   

G1 = No vigorous, <200 kcal/wk

   • G2 = 0.65 (0.46-0.91)

 
   

G2 = No vigorous, ≥ 200 kcal/wk

   • G3 = 1.18 (0.79-1.78)

 
    

   • G4 = 0.96 (0.60-1.55)

 
    

   • G5 = 0.63 (0.38-1.04)

 
   

G3 = Vigorous, 1-199 kcal/wk

  
   

G4 = Vigorous, 200-499 kcal/wk

  
   

G5 = Vigorous, ≥ 500 kcal/wk

  

Paffenbarger et al 1993 [67]

To analyze changes in the lifestyle of Harvard Alumni and the associations of these changes to mortality.

• n = 10,269

Baseline measure in 1962 or 1967 with a follow up in 1977

Alumni who increased their PA index to 2000 kcal or more per week had a 17% lower risk of death from CHD then those who were sedentary (p = 0.507)

Moderately vigorous sports activity was associated with lower rates of death from CHD among middle aged and older men

  

• Sex: Men

   
  

• Age: 45-84 yr

   

USA

 

• Characteristics: Health, Harvard College Alumni

   

Prospective cohort

  

PA assessment: Mailed questionnaires included questions on type, duration, intensity, frequency of PA.

Men who took up moderate took up moderately vigorous activity had a 41% lower risk than those who continued not to engage in such activity (p = 0.044)

 

D & B score = 13

  

Outcome Measure: CHD deaths between 1977 and 1985

  
   

Cox proportional hazards model

  
   

Poisson regression methods

  
   

The Mantel extension of the Mantel-Haenszel test

  

Haapanen et al 1997 [77]

To examine the association between duration and intensity of LTPA and the risk of CHD.

• n = 2,840 (1,500 men; 1,340 women)

Length of Follow-up: 10 yrs

   • Incident Rates (per 1000 person-years) for CHD = 108 for men and 75 for women.

Total EE had an inverse and independent association with risk of CHD in middle aged Finnish men but not among women.

Finland

 

• Sex: Men and women

PA assessment: Questionnaire for LTPA EE (kcal/wk)

Multivariate RR (95% CI) LTPA and CHD mortality

 

Prospective cohort

 

• Age: 35-63 yr

 

Men

 
  

• Characteristics: Healthy

Men

   • G1 = 1.98

 
   

G1 = 0-1100

   • G2 = 1.33

 

D & B score = 13

  

G2 = 1101-1900

   • G3 = 1.00 (referent)

 
   

G3 = >1900

  
    

Women

 
   

Women

   • G1 = 1.25

 
   

G1 = 0-900

   • G2 = 0.73

 
   

G2 = 901-1500

   • G3 = 1.00 (referent)

 
   

G3 = >1500

  
   

Outcome Measure: CHD mortality

  
   

Cox proportional HR

  

Barengo et al 2004 [164]

To investigate whether moderate or high LTPA are associated with a reduced CVD and all-cause mortality, independent of CVD risk factors and other forms of PA in men and women.

• n = 31,677 (15,853 men; 16,824 women)

20 year follow-up

   • Number of Cases (Men): 1,661

Moderate and high levels of LTPA and OPA are associated with reduced CVD mortality.

   

PA assessment: Questionnaire for LTPA and OPA, 3 groups

   • Number of Cases (Women): 778

 

Finland

 

• Sex: Men and women

 

HR (95% CI) LTPA, men

 

Prospective cohort

 

• Age: 30-59

G1 = Low activity

   • G1 = 1.00 (referent)

 
  

• Characteristics: Participant from eastern and south-western Finland

G2 = Moderate activity

   • G2 = 0.91 (0.82-1.00)

 

D & B score = 14

  

G3 = High activity

   • G3 = 0.83 (0.69-0.99)

 
    

LTPA, women (referent)

 
    

   • G1 = 1.00

 
    

   • G2 = 0.83 (0.71-0.96)

 
    

   • G3 = 0.89 (0.68-1.18)

 
    

OPA, men

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.75 (0.64-0.87)

 
    

   • G3 = 0.77 (0.69-0.87)

 
    

OPA, women

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.73 (0.60-0.88)

 
    

   • G3 = 0.77 (0.65-0.91)

 

Bijnen et al 1998 [166]

To describe the association between the PA pattern of elderly men and CHD mortality.

• n = 802

Length of Follow-up: 10

   • Number of Cases: 90

PA did not show a protective effect on death from CHD.

  

• Sex: Men

   
  

• Age: 64-84 yr

PA assessment: Questionnaire, divided into 3 groups

RR (95% CI)

 

Netherlands

 

• Characteristics: Free from Serious Illness

 

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.63 (0.38-1.05)

 

Prospective cohort

  

G1 = Lowest

   • G3 = 0.85 (0.51-1.44)

 
  

• Ethnicity: Dutch

G2 = Middle

  
  

• Zutphen Elderly Study

G3 = Highest

  

D & B score = 13

  

Outcome Measure: CHD Mortality

  
   

Cox Proportional HR

  

Davey-Smith et al 2000 [174]

To examine the association between two measures of physical activity (LTPA and usual walking pace) with cause specific mortality (CHD).

• n = 6,702

Length of Follow-up: 25 yrs

   • Number of Cases: 955

Inverse associations of both LTPA and walking pace with mortality from CHD were seen.

  

• Sex: Men

   
  

• Age: 40-64 yr

 

RR (95% CI) by walking pace

 

England

 

• Whitehall Study

PA assessment: Questionnaire during examination for walking pace and LTPA

   • G1 = 1.45 (0.9-2.2)

 
    

   • G2 = 1.30 (1.1-1.6)

 

Prospective cohort

   

   • G3 = 1.00 (referent)

 
    

p < 0.01

 

D & B score = 11

  

Walking pace

Multivariate RR (95% CI) by LTPA level

 
   

G1 = Slower

   • G1 = 1.24 (1.0-1.5)

 
   

G2 = Same

   • G2 = 0.94 (0.8-1.2)

 
   

G3 = Faster

   • G3 = 1.00

 
    

p < 0.05

 
   

LTPA

  
   

G1 = Inactive

  
   

G2 = Moderate

  
   

G3 = Active

  
   

Outcome Measure: CHD Mortality

  
   

Cox Proportional HR

  

Eaton et al 1995 [175]

To determine whether self reported PA predicts a decreased risk of CHD.

• n = 8,463 (LTPA), 8,418 (OPA)

Length of Follow-up: 21 yrs

   • Number of Cases: 709

Baseline levels of self reported LTPA predicted a decreased rate of CHD.

    

Age adjusted RR (95% CI) by LTPA level

 

USA

 

• Sex: Men

PA assessment: Interview

   • G1 = 1.00 (referent)

 
  

• Age: 40 yr

 

   • G2 = 0.79 (0.63-0.99)

 

Prospective cohort

 

• Characteristics: Healthy, free of CHD

LTPA

   • G3 = 0.73 (0.59-0.89)

 
   

G1 = Sedentary

   • G4 = 0.71 (0.52-0.98)

 
   

G2 = Light

  

D & B score = 11

 

Ethnicity: Israeli

G3 = Light Daily

Age adjusted RR (95% CI) by OPA level

 
   

G4 = Heavy

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.99 (0.75-1.18)

 
   

OPA

   • G3 = 0.94 (0.78-1.12)

 
   

G1 = Sitting

   • G4 = 0.87 (0.67-1.10)

 
   

G3 = Walking

  
   

G4 = Physical Labour

  
   

Outcome Measure: CHD Death

  
   

Cox Proportional HR

  

Hillsdon et al 2004 [183]

To examine whether a short, easily administered measure of PA is associated with the risk of death from all causes and specific causes.

• n = 10,522 (4,929 men; 5,593 women)

Length of Follow-up: > 10 yrs

   • Number of Cases: 155

Self reported VPA is associated with the risk of future mortality.

    

Multivariate RR (95% CI) by PA level

 

UK

 

• Sex: Men and women

PA assessment: Questionnaire, 3 groups:

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.46 (0.19-1.12)

 

Prospective cohort

 

• Age: 35-64 yr

G1 = Never / <1 time/month

   • G3 = 0.96 (0.53-1.75)

 
  

• Characteristics: no history of chest pain

   
   

G2 = <2 times/wk

  

D & B score = 11

  

G3 = ≥ 2 times/wk

  
   

Outcome Measure: IHD mortality

  
   

Cox proportional HR

  

Leon et al 1997 [199]

To study the relationship of PA to CHD in a well defined population at above average risk for CHD over a 16 yr observation period.

• n = 12,138

Follow up for 16 years

Age Adjusted RR (95% CI)

A relatively small amount (10-36 min/d) of daily moderate intensity LTPA can significantly reduce premature mortality from CHD in middle aged men at high risk for CHD.

USA

 

• Sex: Men

 

   • G1 = 1.00 (referent)

 
  

• Age: 35-57 yr

PA assessment: Questionnaire at baseline (Minnesota LTPA questionnaire), divided/grouped into deciles of LTPA (min/d)

   • G2 = 0.71 (0.56-0.91)

 
  

• Characteristics: Free of CHD but in the upper 10-15% of a CHD probability risk score

 

   • G3 = 0.75 (0.59-0.96)

 
    

   • G4 = 0.69 (0.54-0.96)

 

Prospective cohort

   

Multivariate adjusted RR (95% CI)

 
    

   • G1 = 1.00 (referent)

 

D & B score = 11

  

G1 = D1: (0-9 min/d)

   • G2 = 0.75 (0.54-0.96)

 
  

Multiple risk factor intervention trial

G2 = D2-4: (10-36 min/d)

   • G3 = 0.81 (0.64-1.04)

 
   

G3 = D5-7: (37-75 min/d)

   • G4 = 0.75 (0.59-0.96)

 
   

G4 = D8-10: (76-359 min/d)

  
   

Outcome Measure: CHD Mortality

  

Rosengren et al 1997 [211]

To examine the long term effect of OPA and LTPA on the risk of death from CHD.

• n = 7,142

Length of Follow-up: 20 yrs

Number of Cases: 684

There appears to be a protective effect of LTPA on CHD-related death.

  

• Sex: Men

   
  

• Age: 47-55 yr

 

Multivariate RR (95% CI) for LTPA

 

Sweden

 

• Characteristics: Swedish men

PA assessment: Questionnaire for LTPA, 3 groups

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.84 (0.71-1.00)

 

Prospective cohort

   

   • G3 = 0.84 (0.73-0.96)

 
   

G1 = Sedentary

  
   

G2 = Moderately active

  

D & B score = 13

  

G3 = Regular exercise

  
   

Outcome Measure: CHD death

  
   

Proportional HR

  

Schnohr et al 2006 [214]

To describe the associations between different levels of LTPA and subsequent causes of death.

• n = 4,894 (2,136 men; 2,758 women)

Participants included in the study were only those whose PA levels did not change over 5 years

   • Number of Cases: 292

There was an inverse and significant dose- response association between LTPA and CHD-related mortality.

    

Adjusted RR (95% CI) Whole group

 

Denmark

 

• Sex: Men and women

 

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.71 (0.51-0.99)

 

Prospective cohort

 

Age: 20--79 yr

PA assessment:

   • G3 = 0.56 (0.38-0.82)

 
  

• Characteristics: Healthy

Questionnaire LTPA

  

D & B score = 12

 

• Copenhagen City Heart Study

G1 = <4 METS

Men

 
   

G2 = 4-6 METS

   • G1 = referent

 
   

G3 = >6 METS

   • G2 = survived 4.9 yrs longer

 
    

   • G3 = survived 6.8 yrs longer

 
   

Cox proportional HR

  
    

Women

 
    

   • G1 = referent

 
    

   • G2 = survived 5.5 yrs longer

 
    

   • G3 = survived 6.4 yrs longer

 

Weller et al 1998 [220]

To examine the relationship between PA and mortality.

• n = 6,620

Length of Follow-up: 7 yrs

   • Number of Cases: 109

LTPA is inversely associated with risk of fatal MI.

  

• Sex: Women

   
  

• Age: ≥ 30 yr

PA assessment:

OR (95% CI) by LTPA

 

Canada

 

• Characteristics: Canadian Women

Questionnaire, 4 groups for LTPA (kcal/kg/day) and non-LTPA (kcal/kg/day)

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 0.61 (0.07-1.19)

 

Prospective cohort

   

   • Q3 = 0.84 (0.52-1.37)

 
    

   • Q4 = 0.63 (0.36-1.09)

 

D & B score = 9

  

LTPA (kcal/kg/day)

OR (95% CI) by non-LTPA

 
   

Q1 = ≥ 0

   • Q1 = 1.00 (referent)

 
   

Q2 = ≥ 0.1

   • Q2 = 0.71 (0.44-1.16)

 
   

Q3 = ≥ 0.5

   • Q3 = 0.57 (0.33-0.97)

 
   

Q4 = ≥ 1.6

   • Q4 = 0.49 (0.26-0.92)

 
   

Non-LTPA (kcal/kg/day)

  
   

Q1 = ≥ 0

  
   

Q2 = ≥ 2.8

  
   

Q3 = ≥ 5.9

  
   

Q4 = ≥ 9.9

  
   

Outcome Measure: Fatal MI

  
   

Logistic regression analysis

  

Yu et al 2003 [221]

To examine the optimal intensity of LTPA to decrease the risk of CHD mortality in middle aged British men.

• n = 1,975

10 year follow-up

   • Number of Cases: 82

Strong significant inverse relationship between heavy LTPA and CHD mortality.

  

• Sex: Men

PA assessment: Questionnaire (Minnesota LTPA questionnaire), 3 groups

Multivariate adjusted HR (95% CI)

 
  

• Age: 49-64 yr

 

   • G1 = 1.00 (referent)

 

UK

 

• Characteristics: Healthy, no previous history of CHD

 

   • G2 = 0.74 (0.44-1.25)

 
    

   • G3 = 0.55 (0.31-0.98)

 

Prospective cohort

   

p = 0.039

Relationship was not significant for low- moderate intensity LTPA and OPA.

  

• Caerphilly collaborative heart study

Total activity level (kcal/day)

  

D & B score = 11

  

G1 = 0.0 - 161.6

  
   

G2 = 161.8 - 395.3

  
   

G3 = 395.5 - 2747.2

  
   

Cox proportional HR

  

Altieri et al 2004 [222]

To assess the possible protective role of PA on CHD.

• n = 985 (507 men; 478 women)

PA assessment: Questionnaire for OPA, divided into quartiles

Number of Cases: 507

LTPA from 15-19 yrs as well as OPA from 30 - 39 yrs both have a significant inverse relationship with risk of non fatal acute MI.

    

OR (95% CI) for CHD and OPA

 

Italy

 

• Sex: Men and women

Q1 = lowest

   • Q1 = 1.00 (referent)

 
   

Q2

   • Q2 = 0.63 (0.39-1.03)

 

Case Control

 

• Age: < 79 yr

Q3

   • Q3 = 0.56 (0.35-0.90)

 
  

• Characteristics: Case: Patients admitted to Hospital with non-fatal Acute MI. Controls: Patients admitted to hospital for acute condition unrelated to known or potential risk factors for acute MI

Q4 = highest

   • Q4 = 0.57 (0.34-0.95)

 

D & B score = 11

   

p = 0.045

 
   

Outcome Measure: Non Fatal acute MI

  
   

Unconditional logistic regression

  

Batty et al 2003 [223]

To examine the relationship between physical activity and three mortality endpoints in healthy persons.

• n = 6,474

Length of Follow-up: 25 yr

   • Number of Cases: 837

A suggestion that the symptomatic nature of ischemia appeared to modify the affects of

  

• Sex: Men

 

   • Number of Dropouts: 158

 
  

• Age: 40-64 yr

PA assessment: Questionnaire for LTPA, divided into 3 groups:

  

UK

 

• Characteristics: British civil servants who underwent a resting ECG

 

HR (95% CI) for CHD and LTPA

 
    

   • G1 = 1.14 (0.9-1.4)

PA on total and CHD mortality.

Prospective cohort

  

G1 = Inactive

   • G2 = 0.94 (0.8-1.1)

 
   

G2 = Moderate

   • G3 = 1.00 (referent)

 
   

G3 = Active

  

D & B score = 13

     
   

Outcome Measure: CHD mortality

  
   

Cox Proportional HR

  

Chen and Millar [224]

To examine the potential protective effect of LTPA on the incidence of heart disease and depression.

• n = 15,670

Length of Follow-up: 2 yrs

• 100 cases

Regular and at least MPA can be beneficial to heart health.

  

• Sex: Men and women

   
  

• Age: ≥ 20 yr

PA assessment: EE from self administered questionnaire, 4 groups (kcal/kg/day)

Adjusted OR (95% CI)

 

Canada

 

• Characteristics: Healthy and free from heart disease

 

   • G1 = 5.0 (1.84-13.59)

 
    

   • G2 = 3.7 (1.26-10.67)

 

Prospective cohort

   

   • G3 = 1.00 (referent)

 
   

G1 = Sedentary

   • G4 = 1.3 (0.41-3.89)

 
   

G2 = Light (<1.5)

  

D & B score = 11

 

National Population Health Survey

G3 = Moderate (1.5-2.9)

  
   

G4 = Active (≥ 3)

  
   

Outcome Measure: CHD incidence

  
   

Multiple logistic regression

  

Conroy et al 2005 [225]

To examine the relationship between 1) PA during young adulthood and middle age, and 2) PA during each time period and CHD during middle age and older women.

• n = 37,169

Length of Follow-up: 9 yrs

   • Number of Cases: 477

PA during middle age predicts lower risk of CHD

  

• Sex: Women

   
  

• Age: ≥ 45 yr

 

Multivariate RR (95% CI) Baseline PA and incidence of CHD

 

US

 

• Characteristics: Healthy women health professionals

PA assessment: Questionnaire for EE (kcal/wk) and months/yr

  
  

• Women's Health Study

 

   • G1 = 1.00 (referent)

 

Cohort study

   

   • G2 = 0.62 (0.48-0.80)

 
    

   • G3 = 0.61 (0.48-0.79)

 

D & B score = 11

  

Baseline PA (kcal/wk)

   • G4 = 0.61 (0.46-0.81)

 
   

G1 = <200

p = <0.001

 
   

G2 = 200-599

  
   

G3 = 600-1499

Past PA and incidence of CHD

 
   

G4 = ≥ 1500

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.76 (0.57-1.02)

 
   

Past PA

   • G3 = 0.95 (0.72-1.24)

 
   

Months per year

   • G4 = 1.04 (0.78-1.39)

 
   

G1 = 0

   • G5 = 0.81 (0.58-1.14)

 
   

G2 = 1-3

  
   

G3 = 4-6

  
   

G4 = 7-9

  
   

G5 = 10-12

  
   

Outcome Measure: Incidence of CHD

  
   

Cox proportional hazard regression

  

Dorn et al 1999 [226]

To examine the long-term relationships between total PA and mortality from all causes and CHD in the general population.

• n = 1,461 (698 men; 763 women)

Length of Follow-up: 29 years

   • Number of Cases: 109 men, 81 women

PA favorably influences mortality risks in non- obese men and younger women.

USA

 

• Sex: Men and women

PA assessment: Questionnaire

Multivariate RR (95% CI) for PAI in non- obese men

 

Prospective cohort

 

• Age: 15-96 yr

 

   • 0.40 (0.19-0.88) for 1 kcal/kg/h

 
  

• Characteristics:

Outcome Measure: CHD

Multivariate RR (95% CI) for PAI in obese men

 
  

Healthy, free from CHD, diabetes, and Stroke.

Mortality

   • 1.86 (0.86-4.03) for 1 kcal/kg/h

 

D & B score = 11

     
   

Cox Proportional Hazard

  
   

Ratio

Multivariate RR (95% CI) for PAI in women < 60 yrs

 
  

• Ethnicity: White.

 

   • 0.42 (0.11-1.52) for 1 kcal/kg/h

 
    

Multivariate RR (95% CI) for PAI in women > 60 yrs

 
    

   • 1.78 (0.77-4.09) for 1 kcal/kg/h

 

Folsom et al 1997 [227]

To examine the association of PA at baseline with CHD incidence.

• n = 13,999 (6,166 men; 7833 women)

Length of Follow-up: 4-7 yrs

   • Number of Cases: 223 men, 97 women,

No significant relationships.

    

Multivariate RR (95% CI) LTPA, men

 

USA

 

• Sex: Men and women

PA assessment: Questionnaire during home interview, divided into quartiles of LTPA and sports activity

  
    

   • Q1 = 1.00 (referent)

 

Prospective cohort

 

• Age: 45-64 yr

 

   • Q2 = 1.08 (0.75-1.55)

 
  

• Characteristics: no CHD at baseline

 

   • Q3 = 0.83 (0.51-1.36)

 
    

   • Q4 = 0.89 (0.59-1.35)

 

D & B score = 9

  

Q1 = Low

  
  

• Ethnicity: Black and non Black

Q2

LTPA, women

 
   

Q3

   • Q1 = 1.00 (referent)

 
  

• Atherosclerosis Risk in Communities Study

Q4 = High

   • Q2 = 0.74 (0.42-1.31)

 
    

   • Q3 = 1.07 (0.55-2.09)

 
   

Outcome Measure: CHD incidence Poisson Regression

   • Q4 = 0.64 (0.34-1.24)

 
    

Multivariate RR (95% CI) Sports, men

 
    

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 1.15 (0.79-1.68)

 
    

   • Q3 = 1.03 (0.68-1.54)

 
    

   • Q4 = 0.83 (0.56-1.23)

 
    

Sports, women

 
    

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 0.99 (0.58-1.67)

 
    

   • Q3 = 0.64 (0.32-1.27)

 
    

   • Q4 = 0.72 (0.37-1.38)

 

Fransson et al 2004 [228]

To estimate the influence of LTPA and OPA on acute MI.

• n = 4069 (2,742 men; 1,327 women)

PA assessment: Questionnaire for LTPA, 5 groups

   • Number of Cases: 1,204 men, 550 women

Exercise seems to reduce the risk of MI.

Sweden

 

• Sex: Men and Women

G1 = Seldom

OR (95% CI)

 
   

G2 = Sometimes

  

Case Control

 

• Age: 45-70 yr

G3 = 1×/wk

LTPA, men

 
  

• Characteristics: Cases: Diagnosed with acute MI

G4 = 2-3×/wk

   • G1 = 1.00 (referent)

 

D & B score = 12

  

G5 = >3×/wk

   • G2 = 0.76 (0.61-0.95)

 
    

   • G3 = 0.67 (0.51-0.88)

 
    

   • G4 = 0.63 (0.49-0.83)

 
  

• Stockholm Heart Epidemiology

Questionnaire for total physical activity, 3 groups

   • G5 = 0.53 (0.38-0.73)

 
   

G1 = Passive

  
   

G2 = Somewhat active

LTPA, women

 
   

G3 = Active

   • G1 = 1.00 (referent)

 
   

Questionnaire for sitting at work, 3 groups

   • G2 = 0.69 (0.49-0.98)

 
    

   • G3 = 0.38 (0.25-0.58)

 
   

G1 = Less than half the time

   • G4 = 0.62 (0.38-1.01)

 
   

G2 = About half the time

   • G5 = 0.31 (0.15-0.66)

 
   

G3 = More than half the time

Total physical activity, men

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.66 (0.47-0.94)

 
   

Outcome Measure: Acute MI

   • G3 = 0.46 (0.31-0.69)

 
    

Total physical activity, women

 
   

Conditional and unconditional logistics regression

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.34 (0.22-0.53)

 
    

   • G3 = 0.16 (0.07-0.37)

 
    

Sitting at work, men

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.91 (0.73-1.15)

 
    

   • G3 = 0.90 (0.72-1.12)

 
    

Sitting at work, women

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.77 (0.51-1.17)

 
    

   • G3 = 0.47 (0.31-0.69)

 

Fransson et al 2006 [229]

To evaluate whether LTPA compensates for the increased risk of acute MI associated with overweight and obesity.

• n = 4069 (2,742 men; 1,327 women)

PA Assessment: Questionnaire for LTPA, 3 groups

Number of Cases: 1204 men, 550 women

Regular LTPA seems to provide protection against MI and non- fatal MI.

    

Multivariate OR (95% CI) for acute MI

 

Sweden

 

• Sex: Men and women

G1 = Very little /occasional walks

LTPA, men

 
    

   • G1 = 1.00 (referent)

 

Case Control

 

• Age: 45-70 yr

G2 = Occasional / once per week

   • G2 = 0.70 (0.58-0.84)

 
  

• Characteristics: Cases: had acute MI

 

   • G3 = 0.57 (0.46-0.71)

 

D & B score = 12

  

G3 = Twice per week or more

LTPA, women

 
    

   • G1 = 1.00 (referent)

 
   

Outcome measure: Acute MI

   • G2 = 0.52 (0.40-0.68)

 
    

   • G3 = 0.44 (0.30-0.65)

 
    

Multivariate OR (95% CI) for non-fatal MI

 
   

Conditional and unconditional logistics regression

LTPA, men

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.79 (0.65-0.96)

 
    

   • G3 = 0.63 (0.50-0.79)

 
    

LTPA, women

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.64 (0.48-0.86)

 
    

   • G3 = 0.58 (0.39-0.87)

 

Haapanen-Niemi 2000 [230]

To investigate the independent associations and the possible interaction of BMI LTPA and perceived physical performance and functional capacity with the risk of mortality.

• n = 2,212 (1,090 men; 1,122 women)

Length of Follow-up: 16 yrs

   • Number of Cases: 208 all cause deaths, 54% of those CVD. 73% of CVD deaths due to CHD

Increase perceived PF is associated with a reduced risk of CHD mortality in men.

Finland

 

• Sex: Men and women

PA assessment: Postal Survey

  
    

Multivariate RR (95% CI)

 

Prospective cohort

 

• Age: 35-63 yr

Total LTPA energy expenditure (kcal/wk)

Total LTPA EE index and CHD mortality, men

 
  

• Characteristics:

Healthy

 

   • G1 = 1.00 (referent)

 
   

G1 = High

   • G2 = 0.88 (0.44-1.76)

 

D & B score = 13

 

• Ethnicity:

Finnish

G2 = Moderate

   • G3 = 1.70 (0.90-3.21)

 
   

G3 = Low

p = 0.056

 
   

Perceived physical fitness compared to age-mates

Multivariate RR (95% CI) Perceived physical fitness, men

 
   

G1 = Better

   • G1 = 1.00 (referent)

 
   

G2 = Similar

   • G2 = 2.82 (1.06-7.46)

 
   

G3 = Worse

   • G3 = 4.64 (1.56-13.84)

 
   

Outcome Measure: CHD mortality

p = 0.011

 
    

Total LTPA EE index and CHD mortality, women

 
   

Cox proportional HR

  
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.43 (0.16-1.16)

 
    

   • G3 = 1.17 (0.51-2.68)

 
    

p = 0.046

 
    

Multivariate RR (95% CI) Perceived physical fitness, women

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.82 (0.32-2.16)

 
    

   • G3 = 1.89 (0.57-6.27)

 
    

p = 0.154

 

Kannel et al 1986 [231]

To examine the role of low levels of OPA and LTPA in the development of CV morbidity and mortality over the short and long term.

• n = 1,166

Length of Follow-up: 24 yrs

   • Number of Cases: 220 mortality, 371 morbidity

Rate of CHD Mortality and Morbidity decreases with increased level of PA but no association was found with physical demand of work

  

• Sex: Men

   
  

• Age: 45-65 yr

   

USA

 

• Characteristics:

PA assessment: Questionnaire during examination

Cumulative 24 year age adjusted rate per 1000 people

 

Prospective cohort

   

24 hr PA index for LTPA CHD mortality

 
   

PA index:

   • G1 = 255

 

D & B score = 11

  

G1 = <29

   • G2 = 184

 
   

G2 = 30-34

   • G3 = 152

 
   

G3 = >34

p < 0.01

 
   

Physical demand of work

24 hr PA index for LTPA CHD incidence

 
   

G1 = Sedentary

   • G1 = 414

 
   

G2 = Light

   • G2 = 353

 
   

G3 = Medium

   • G3 = 311

 
   

G4 = Heavy

  
   

Outcome Measure: CHD mortality and Morbidity

Physical demand of work and CHD mortality

 
    

   • G1 = 216

 
   

Cox proportional HR

   • G2 = 209

 
    

   • G3 = 169

 
    

   • G4 = 170

 
    

Physical demand of work and CHD incidence:

 
    

   • G1 = 355

 
    

   • G2 = 405

 
    

   • G3 = 307

 
    

   • G4 = 325

 

Kaprio et al 2000 [232]

To examine the contribution of genetic and other familial factors to the relationship between LTPA and CHD.

• n = 8,205

Length of Follow-up: 18 yrs

   • Number of Cases: 723

LTPA compared to being sedentary helps prevent CHD in men.

  

• Sex: Men

   
  

• Age: 25-69 yr

 

Multivariate RR (95% CI)

 

Finland

 

• Characteristics: Same sex twin pairs, free of CVD

PA assessment: Questionnaire for LTPA, 3 groups:

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.84 (0.70-1.01)

 

Prospective cohort

   

   • G3 = 0.68 (0.50-0.92)

 
   

G1 = Sedentary

p = 0.010

 
   

G2 = Occasional

  

D & B score = 12

  

Exercisers

  
   

G3 = Conditioning

  
   

Exercisers

  
   

Outcome Measure: Hospitalization or death from CHD

  
   

Poisson regression

  

Lakka et al 1994 [233]

To investigate the independent associations of LTPA and maximal oxygen uptake with the risk of acute MI.

• n = 1,166

Baseline examination: 1984-1989

 

Conditioning LTPA and VO2 max had an inverse, graded and independent association with the risk

  

• Sex: Men

   
  

• Age: 42-61 yr

 

Adjusted RH (95% CI) by conditioning PA level

 

Finland

 

• Characteristics: Healthy with normal ECG

PA assessment: Questionnaire for conditioning PA (h/wk), 3 groups (h/wk)

  
   

G1 = <0.7

   • G1 = 1.00 (referent)

 

Prospective cohort

  

G2 = 0.7

   • G2 = 1.11 (0.58-2.12)

 
  

• Kuopio Ischaemic Heart Disease Risk Factor Study

G3 = >2.2

   • G3 = 0.31(0.12-0.85)

 

D & B score = 13

   

Adjusted RG (95% CI) by VO2 max

 
    

   • G1 = 1.00

 
   

PF assessment: VO2 max (ml/kg/min)

   • G2 = 0.76 (0.38-1.50)

 
    

   • G3 = 0.26 (0.10-0.68)

 
   

G1 = <28.0

  
   

G2 = 28.0-33.6

  
   

G3 = >33.6

  
   

Outcome event: acute MI

  
   

Cox proportional HR

  

Laukkanen at al 2004 [234]

To determine whether VO2peak predicts CVD morbidity and mortality in a sample of men as related to conventional risk factors, medications or underlying chronic disease.

• 1,294 healthy; 1,057 unhealthy

PF Assessment: VO2 peak (ml/kg/min) measured by exercise test with an electrically braked cycle ergometer, divided into quartiles

   • Number of Cases: 204 CV deaths, 323 non-fatal coronary events

Dose-response relationship between directly measured PF and CVD death among healthy men at baseline.

Finland

 

• Sex: Men

 

Healthy men with low VO2 peak (lowest quartile) had an increased risk

 
  

• Age: 42-60 yr

   

Prospective cohort

 

• Characteristics: Healthy and not healthy participants

   
   

Q1 = <27.6

Adjusted RR (95% CI) by PF quartile Fatal MI

 
   

Q2 = 27.6-32.2

 

Unfit men with unfavorable risk profiles are the risk group that would benefit the most from preventative measures.

D & B score = 11

  

Q3 = 32.3-37.1

   • 3.29 (0.86-12.90)

 
  

• Kuopio Ischaemic Heart Disease Risk Factor Study

Q4 = >37.2

  
    

Non-Fatal MI

 
   

Outcome Measure: Incidence of fatal and non fatal CVD during 13 year follow-up

   • 2.16 (1.12-4.18)

 
   

Cox proportional HR

  

Lee at al 2000 [235]

To investigate whether different durations of exercise episode are associated with different risk of CHD.

• n = 7,307

Baseline survey in 1988

   • Number of Cases: 482

Longer durations of PA bouts are not associated with decreased CHD risk compared with shorter bouts, once total EE is taken into account.

  

• Sex: Men

   

USA

 

• Age: Mean 66.1 ± 7.5

PA assessment: Survey for EE (kJ/wk), divided into 5 groups and episodes of PA (min), divided into 6 groups

Multivariate adjusted RR (95% CI) by EE

 
    

   • G1 = 1.00 (referent)

 
  

• Characteristics: Healthy

 

   • G2 = 0.80 (0.57-1.12)

 
    

   • G3 = 0.80 (0.55-1.16)

 

Prospective cohort

 

• Harvard Alumni Study

 

   • G4 = 0.74 (0.47-1.17)

 
    

   • G5 = 0.62 (0.41-0.94)

 

D & B score = 12

  

Energy expenditure (kJ/wk)

 

As long as the total EE is similar, more frequent shorter bouts or longer less frequent bouts have an equivalent reduction in CHD risk.

   

G1 = <4,200

Multivariate adjusted RR (95% CI) by duration of PA episode

 
   

G2 = 4,200-8,399

  
   

G3 = 8,400-12,599

  
   

G4 = 12,600-16,799

   • G1 = 1.00 (referent)

 
   

G5 = ≥ 16,800

   • G2 = 1.15 (0.70-1.87)

 
    

   • G3 = 1.01 (0.68-1.51)

 
    

   • G4 = 1.11 (0.67-1.84)

 
   

Duration of PA episode (min)

   • G5 = 1.18 (0.77-1.80)

 
   

G1 = None

   • G6 = 1.25 (0.83-1.87)

 
   

G2 = 1-15

  
   

G3 = 16-30

  
   

G4 = 31-45

  
   

G5 = 46-60

  
   

G6 = >60

  
   

Outcome Measure: Fatal and Non Fatal CHD

  
   

Proportional hazards regression

  

Lee et al 2003 [236]

To investigate whether moderate- intensity exercise is associated with reduced CHD.

• n = 7,337

PA assessment: Survey rating usual level of exertion when exercising, divided into tertiles

   • Number of Cases: 551

Inverse association between relative intensity of PA and the risk of CHD.

USA

 

• Sex: Male

 

Multivariate adjustment RR (95% CI)

 
  

• Age: Mean 66.1 yr

 

   • T1 = 1.00 (referent)

 
    

   • T2 = 0.87 (0.70-1.09)

 
  

• Characteristics: Healthy

 

   • T3 = 0.92 (0.75-1.14)

 

Prospective cohort

  

Energy expenditure (kcal/wk)

  
  

Harvard Alumni Study

   
   

T1 = <1000

  

D & B score = 13

  

T2 = 1000-2499

  
   

T3 = ≥ 2500

  
   

Cox proportional HR

  

Lemaitre et al 1999 [237]

To investigate whether regular participation in moderate intensity activity confers overall protection from sudden primary cardiac arrest.

• n = 355 cases, 503 controls

PA assessment: Interview (with spouses) for LTPA, 7 groups

   • 355 cases

Participation in moderate intensity LTPA was associated with a decreased risk of primary cardiac arrest.

  

• Sex: Men and women

 

RR (95% CI)

 

USA

  

G1 = No activity

   • G1 = 1.00 (referent)

 
  

• Age: 25-74 yr

G2 = Gardening only≤ 60 min/wk

   • G2 = 0.52 (0.21-1.28)

 

Case control

 

• Characteristics: Previously healthy prior to primary cardiac arrest. Control Subjects: Individually matched to case patients on age (within 7 years) and sex at a ratio of about 2:1 were randomly selected from community by random-digit dialing

G3 = Gardening only > 60 min/wk

   • G3 = 0.34 (0.13 0.89)

 
   

G4 = Walking ≤ 60 min/wk

   • G4 = 0.45 (0.17-1.19)

 

D & B score = 11

  

G5 = Walking > 60 min/wk

   • G5 = 0.27 (0.11-0.67)

 
   

G6 = Moderate intensity

   • G6 = 0.31 (0.13-0.74)

 
   

LTPA (not walking or gardening)

G7 = 0.34 (0.16-0.75)

 
   

G7 = High intensity LTPA

  
   

Logistic regression analysis

  

Lemaitre et al 1995 [238]

To examine whether LTPA decreases the risk of MI in postmenopausal women.

• n = 1,193

PA assessment: Phone interview for LTPA, divided into quartiles of EE (mean kcal/wk)

   • Number of Cases: 268

Risk of MI among postmenopausal women is decreased by 50% with modest LT energy expenditures, equivalent to 30-45 min of walking for exercise three times per week

  

• Sex: Women

   
  

• Age: Mean 67 yr

 

Multivariate RR (95% CI)

 

USA

   

   • Q1 = 1.00 (referent)

 
  

• Characteristics: Postmenopaus al Cases: Diagnosed with non-fatal MI Controls: free from MI

Q1 = 71

   • Q2 = 0.52 (0.34-0.80)

 

Case control

  

Q2 = 472

   • Q3 = 0.40 (0.26-0.63)

 
   

Q3 = 1183

   • Q4 = 0.40 (0.25-0.63)

 

D & B score = 11

  

Q4 = 3576

p = <0.001

 
   

Outcome Measure: Diagnosed with non-fatal MI

  
   

Logistic regression analysis

  

Li et al 2006 [239]

To examine independent and joint associations of PA and adiposity with CHD incidence.

• n = 88,393

Length of Follow-up: 20 yrs

   • Number of Cases: 2,358

Physical inactivity independently contributes to the development of CHD in women.

  

• Sex: Women

 

   • Number of Dropouts: <2% lost to follow-contributes to the development of CHD in women.

 

USA

 

• Age: 34-59 yr

 

up

 
  

• Characteristics: Nurses

PA assessment: Questionnaire for LTPA (hr/wk), 3 groups

  

Prospective cohort

   

Multivariate HR (95% CI)

 
  

• Nurses' Health Study

 

   • G1 = 1.00 (referent)

 
   

G1 = ≥3.5

   • G2 = 1.34 (1.18-1.51)

 

D & B score = 12

  

G2 = 1-3.49

   • G3 = 1.43 (1.26-1.63)

 
   

G3 = <1

  
   

Outcome Measure: CHD incidence

  
   

Cox proportional HR

  

Lemaitre et al 1995 [240]

To evaluate the effect of PA on MI occurrence.

• n = 1,107 (726 controls, 381 cases)

PA assessment: Questionnaire, 3-5 groups depending on variable

OR (95% CI),

PA level was inversely associated with occurrence of MI in both sexes, although the association presented a significant linear trend only for women; in men it suggested a u-shaped relation.

    

Total PA, men

 

Portugal

 

• Sex: Men and women

 

   • G1 = 1.00 (referent)

 
   

Total PA (MET hr/day), men

   • G2 = 0.54 (0.33-0.88)

 

Case control

 

• Age: ≥ 40 yr

 

   • G3 = 0.34 (0.20-0.59)

 
  

• Characteristics: Case: Admitted to Hospital and diagnosed with first episode of MI Control: Healthy, no history of CHD

G1 = 28.3-32.1

   • G4 = 0.59 (0.36-0.98)

 

D & B score = 12

  

G2 = 32.2-33.3

   • G5 = 0.90 (0.56-1.45)

 
   

G3 = 33.4-36.5

Trend p = 0.827

 
   

G4 = 36.6-40.3

Total PA, women

 
   

G5 = 40.4-83.1

   • Q1 = 1.00 (referent)

 
   

Total PA (MET hr/day), women

   • Q2 = 0.39 (0.21-0.73)

 
   

Q1 = 28.9-32.7

   • Q3 = 0.33 (0.17-0.64)

 
   

Q2 = 32.8-34.1

   • Q4 = 0.22 (0.11-0.47)

 
   

Q3 = 34.2-37.8

p = <0.001

 
   

Q4 = 37.8-70.6

  
    

Sport participation, men

 
   

Sport participation (MET hr/day), men

   • G1 = 1.00 (referent)

 
   

G1 = 0.0

   • G2 = 0.36 (0.19-0.69),

 
   

G2 = 0.1-1.0

   • G3 = 0.72 (0.41-1.26),

 
   

G3 = 1.1-2.0

   • G4 = 0.42 (0.23-0.76),

 
   

G4 = 2.1-3.6

   • G5 = 0.31 (0.16-0.62)

 
   

G5 = 3.7-15.4

p = <0.001

 

Lovasi et al 2007 [241]

To investigate the shape of the relationship between LTPA and MI risk.

• n = 4,094

PA assessment: Telephone interview (Minnesota LTPA Questionnaire)

   • Number of Cases: 697

Time engaged in LTPA, even non strenuous LTPA was associated with a lower risk of MI, and the shape of this relationship was non- linear

  

• Sex: Men and women

 

Adjusted OR (95% CI)

 

USA

 

• Age: 64 ± 9 yr

 

LTPA and non fatal CHD

 
  

• Characteristics: Group Health Cooperative Members

 

   • G1 = 1.00 (referent)

 

Case control

  

LTPA

   • G2 = 0.88 (0.66-1.17)

 
   

G1 = None

   • G3 = 0.62 (0.46-0.83)

 

D & B score = 11

  

G2 = <2

   • G4 = 0.61 (0.45-0.82)

 
   

G3 = 2-5

   • G5 = 0.59 (0.44-0.80)

 
   

G4 = 5-9

  
   

G5 = >9 h/wk

Adjusted RR (95% CI) Strenuous LTPA and non Fatal CHD

 
   

Strenuous LTPA

   • G1 = 1.00 (referent)

 
   

G1 = None

   • G2 = 0.76 (0.59-0.99)

 
   

G2 = non strenuous LTPA

   • G3 = 0.53 (0.40-0.70)

 
   

G3 = Any Strenuous

  
   

LTPA

  
   

Outcome measure: non fatal CHD

  
   

Logistic regression

  

Manson et al 1999 [242]

To assess the comparative roles of walking and vigorous exercise in the prevention of coronary events in women.

• n = 72,488

PA assessment:

   • Number of Cases: 645 coronary events

Both walking and VPA are associated with a substantial reductions in incidence of CHD. Risk reductions for each were similar hen total PAy was similar. Walking 3 or more hours per week could reduce the risk of CHD by 30-40%.

  

• Sex: Women

Questionnaire with detailed information on PA.

  
  

• Age: 40-65 yr

 

Multivariate RR (95% CI) by total PA score

 

USA

 

• Characteristics: Healthy, no Previous history of CHD

 

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.88 (0.71-1.10)

 

Prospective cohort

  

Total PA score

   • G3 = 0.81(0.64-1.02)

 
   

G1 = 1-2.0

   • G4 = 0.74 (0.58-0.95)

 
  

Nurses' Health Study

G2 = 2.1-4.6

   • G5 = 0.66 (0.51-0.86)

 

D & B score = 12

  

G3 = 4.7-10.4

p = 0.002

 
   

G4 = 10.5-21.7

  
   

G5 = >21.7

  
    

Multivariate RR (95% CI) by walking activity

 
    

   • G1 = 1.00 (referent)

 
   

Walking, in those who did not participate in VPA: (MET hr/wk)

   • G2 = 0.78 (0.57-1.06)

 
   

G1 = 0.5

   • G3 = 0.88 (0.65-1.21)

 
   

G2 = 0.6-2.0

   • G4 = 0.70 (0.51-0.95)

 
   

G3 = 2.1-3.8

   • G5 = 0.65 (0.47-0.91)

 
   

G4 = 3.9-9.9

p = 0.02

 
   

G5 = ≥ 10

  
    

Multivariate RR (95% CI) by walking pace

 
    

   • 1.00 (referent)

 
   

Walking pace (mph)

   • 0.75 (0.59-0.96)

 
   

G1 = <2.0

   • 0.64 (0.47-0.88)

 
   

G2 = 2.0-2.9

  
   

G3 = ≥ 3.0

  

Mora et al 2007 [243]

To investigate whether differences in several CV risk factors mediate the effect of PA on reduced risk of CVD.

• n = 27,055

10.9 ± 1.6 yr of follow up

   • Number of Cases: 640

There remained a borderline significant inverse association between PA and risk of CHD after adjustment for all sets of risk factors.

  

• Sex: Women

   
  

• Age: ≥ 45 yr

PA assessment: Questionnaires at study entry for categories of EE from PA (kcal/wk), 4 groups

HR (95% CI), basic model

 

USA

 

• Characteristics: Healthy

 

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.84 (0.67-1.06)

 

Prospective cohort

 

• Women's health study

 

   • G3 = 0.76 (0.61-0.96)

 
    

   • G4 = 0.62 (0.48-0.82)

 
   

G1 = <200

p = 0.001

 

D & B score = 13

  

G2 = 200-599

 

While all sets of risk factors should some mediation on the effect of PA on CHD none made the relationship insignificant

   

G3 = 600-1499

Multivariate adjusted HR (95% CI)

 
   

G4 = ≥ 1500

   • G1 = 1.00 (referent)

 
    

   • G2= 0.71 (0.58-0.87)

 
   

Outcome measure:

   • G3 = 0.64 (0.52-0.78)

 
   

Incidence of CVD and

   • G4 = 0.48 (0.38-0.62)

 
    

p = <0.001

 
   

Cox proportional HR

  

O'Connor et al 1995 [244]

To examine the association between intensity of exercise and CHD risk.

• n = 680 (532 men and 148 women)

PA assessment: Home interview for PA, divided into quartiles

   • Number of Cases: 340

Significant inverse association between PA level and the risk of non fatal MI in men, which persisted after adjustment for other risk factors.

    

Adjusted OR (95% CI) by PA level, men

 
    

   • Q1 = 1.00 (referent)

 

USA

 

• Sex: Men and women

Q1 = Lowest

   • Q2 = 0.60 (0.32-1.13)

 
   

Q2

   • Q3 = 0.41 (0.21-0.78)

 

Case control

 

• Age: < 76 yr

Q3

   • Q4 = 0.41 (0.22-0.77)

 
  

• Characteristics: Cases: Diagnosed MI (non-fatal), no previous history of CHD. Controls: no history of CHD.

Q4 = Highest

p = 0.003

 

D & B score = 12

  

Outcome Measure: non-fatal MI

Adjusted OR (95% CI) by PA level, women

 
    

   • Q1 = 1.00 (referent)

 
   

Moderate- vigorous sports men Cut-points kcal/wk

   • Q2 = 1.07 (0.27-4.17)

 
   

Q1 = Lowest

   • Q3 = 2.02 (0.56-7.38)

 
   

Q2

   • Q4 = 1.29 (0.31-5.35)

 
   

Q3

p = 0.51

 
   

Q4 = Highest

  
    

Adjusted OR (95% CI) by moderate-vigorous sports, men

 
    

   • Q1 = 1.00 (referent)

 
   

Moderate- vigorous sports Women

   • Q2 = 1.12 (0.60-2.10)

 
   

Cut-points kcal/wk

   • Q3 = 0.61 (0.30-1.24)

 
   

Q1 = Lowest

   • Q4 = 0.43 (0.20-0.92)

 
   

Q2

p = 0.02

 
   

Q3

  
   

Q4 = Highest

Adjusted OR (95% CI) by moderate-vigorous sports, women

 
   

Logistic regression analysis

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 1.31 (0.37-4.66)

 
    

   • Q3 = 1.90 (0.44-8.28)

 
    

   • Q4 = 0.35 (0.07-1.84)

 
    

p = 0.62

 

Rastogi et al 2004 [245]

To examine the relation between PA and CHD risk in India.

• n = 1,050

PA assessment: Questionnaire

Number of Cases: 350

Observed a strong and dose dependent inverse association between LTPA and non fatal CHD.

  

• Sex: Men and women

 

Multivariate OR (95% CI) by LTPA

 

USA

 

• Age: 21-74 yr

LTPA (MET min/d)

   • G1 = 1.00 (referent)

 
  

• Characteristics: Cases: Diagnosed with MI (non fatal) Controls: non- cardiac patients

G1 = 0

   • G2 = 0.96 (0.59-1.55)

 

Case control

  

G2 = 0-145

   • G3 = 0.44 (0.27-0.71)

 

D & B score = 12

  

G3 = ≥145

p = 0.001

 
   

Sedentary time (min/d)

Multivariate OR (95% CI) by sedentary time

 
   

G1 = <70

   • G1 = 1.00 (referent)

 
   

G2 = 70-130

   • G2 = 1.15 (0.68-1.95)

 
   

G3 = 130-215

   • G3 = 1.04 (0.61-1.76)

 
   

G4 = ≥215

   • G4 = 1.88 (1.09-3.21)

 
    

p = 0.02

 
   

Outcome Measure: Non-fatal MI

  
   

Conditional logistic regression

  

Rodriguez et al 1994 [246]

To examine the relationship between PA and 23 yr incidence of CHD morbidity and mortality.

• n = 7,074

23 year follow-up

   • Number of Cases: 789

PA was associated with a significant reduction in the risk of CHD morbidity and mortality.

  

• Sex: Men

   
  

• Age: 45-64 yr

PA assessment: Questionnaire for PA index, divided into tertiles

Age adjusted RR (95% CI), CHD incidence

 

USA

 

• Characteristics: Japanese- American living in Oahu, Hawaii in 1965, < 65 years to reduce effect of retirement on PA levels

 

   • T1 = 1.00 (referent)

 
    

   • T2 = 1.01 (.86-1.19)

 

Prospective cohort

  

T1 = Low

   • T3 = 0.83 (0.86-1.19)

These data support the hypothesis that PA is associated with a favorable profile of CVD risk factors.

   

T2 = Moderate

  
   

T3 = High

Multivariate adjusted RR (95% CI), CHD incidence

 

D & B score = 11

  

Cox proportional regression model

   • T1 = 1.00 (referent)

 
    

   • T2 = 1.07 (0.90-1.26)

This study did not show a dose- response relationship since the medium tertile of PA showed increased rates of CHD compared to the inactive group.

  

• The Honolulu Heart Program

 

   • T3 = 0.95 (0.80-1.14)

 
    

Age adjusted RR (95% CI), CHD mortality

 
    

   • T1 = 1.00 (referent)

 
    

   • T2 = 1.12 (0.88-1.44)

 
    

   • T3 = 0.74 (0.56-0.97)

 
    

Multivariate adjusted RR (95% CI)

 
    

   • T1 = 1.00 (referent)

 
    

   • T2 = 1.19 (0.93-1.53)

 
    

   • T3 = 0.85 (0.65-1.13)

 

Rothenbacher et al 2003 [247]

To estimate the risk for CHD associated with LTPA.

• n = 791 (312 cases; 479 controls)

PA assessment: Interview

Number of Cases: 312

LTPA showed a clear inverse association with risk of CHD.

   

LTPA (h/wk)

Multivariate OR (95% CI), LTPA

 

Germany

 

• Sex: Men and Women

G1 = 0

Winter

 
   

G2 = <1

   • G1 = 1.00 (referent)

 

Case control

 

Age: 40-68 yr

G3 = 1-2

   • G2 = 0.48 (0.27-0.84)

 
  

Characteristics: Cases: stable CHD diagnosed within 2 years, no recent MI, Controls: no history of CHD.

G4 = >2

   • G3 = 0.54 (0.369-0.82)

 

D & B score = 12

   

   • G4 = 0.27 (0.19-0.47)

 
   

Workday activity by

  
   

bike/foot, (min/workday)

Summer

 
   

G1 = <15

   • G1 = 1.00 (referent)

 
   

G2 = 15-30

   • G2 = 0.85 (0.47-1.53)

 
   

G3 = 30-60

   • G3 = 0.60 (0.38-0.95)

 
   

G4 = >60

   • G4 = 0.39 (0.26-0.59)

 
   

Outcome Measure: non fatal CHD

Multivariate OR (95% CI), workday activity by bike/foot

 
   

Unconditional logistic regression, linear regression model

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.53 (0.30-0.93)

 
    

   • G3 = 0.36 (0.21-0.62)

 
    

   • G4 = 0.58 (0.36-0.94)

 

Seccareccia and Menotti 1992 [248]

To examine the relationship between OPA and the risk of CHD death.

• n = 1,621

25 year of follow-up

• 189 cases

Increase in OPA is inversely related to risk of CHD death.

  

• Sex: Men

   
  

• Age: 40-59 yr

PA assessment: Questionnaire for OPA (kcal/d), 3 groups

Age Standardized CHD and deaths rates:

 
  

• Characteristics: Healthy

 

   • G1 = 18.9 ± 3.1

 

Italy

   

   • G2 = 13.1 ± 1.7

 
   

G1 = Sedentary, < 2400

   • G3 = 11.0 ± 0.9

 

Prospective cohort

  

G2 = Moderate, 2400-3199

  

D & B score = 11

  

G3 = Heavy ≥ 3200

  
   

Indicators of PF including HR, vital capacity, FEV in 3/4 of sec, and corrected arm circumference (minus contribution of fat).

  
   

End Point: Fatal CHD

  

Sesso et al 2000 [249]

To examine the association of the quantity and intensity of PA with CHD risk and the impact of other coronary risk factors.

• n = 12,516

PA assessment: Questionnaire

Number of Cases: 2,135

L-Shaped association between PA and the risk of CHD, with a reduction in CHD risk of approximately 20% for total PA levels >4200 kJ/wk

  

• Sex: Men

   
  

• Age: 39-88 yr

 

Multivariate HR (95% CI)

 

USA

 

• Characteristics: Healthy

PA Index (kJ/wk)

   • G1 = 1.00 (referent)

 
   

G1 = <2100

   • G2 = 0.90 (0.79-1.03)

 

Prospective cohort

 

• Harvard Alumni

G2 = 2100-4199

   • G3 = 0.81 (0.71-0.92)

 
  

Study

G3 = 4200-8399

   • G4 = 0.80 (0.69-0.93)

 
   

G4 = 8400-12599

   • G5 = 0.81 (0.71-0.94)

 

D & B score = 12

  

G5 = >12600

p = 0.003

Suggests that vigorous activities are associated with a reduced risk of CHD, whereas moderate or light PA has no clear association with risk of CHD.

   

Cox proportional HR

  

Sundquist et al 2005 [250]

To examine the long term effect of LTPA on incident cases of CHD.

• n = 5,196 (2,645 men, 2,551 women)

PA assessment: Questionnaire Levels of PA

Age and sex adjusted RR (95% CI)

Positive long term effect of LTPA on CHD risk among men and women.

    

   • Q1 = 1.00 (referent)

 

Sweden

 

• Sex: Men and women

Q1 = None

   • Q2 = 0.72 (0.51-1.00)

 
   

Q2 = Occasionally

   • Q3 = 0.64 (0.46-0.89)

 

Prospective cohort

 

Age: 35-74 yr

Q3 = 1-2 times per week

   • Q4 = 0.46 (0.29-0.74)

 
  

• Characteristics: Those not hospitalized for CHD in the last 2 years and those who rate their general health as poor were excluded

Q4 = Vigorous ≥2 times per week

Multivariate adjusted RR (95% CI)

 

D & B score = 11

  

Outcome Measure: Fatal or non fatal CHD

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 0.76 (0.55-1.07)

 
    

   • Q3 = 0.74 (0.53-1.04)

 
    

   • Q4 = 0.59 (0.37-0.95)

 
   

Cox regression model

  

Talbot et al 2002 [251]

To examine the contributions of LTPA and aerobic fitness to the risk of coronary events in healthy younger and older adults.

• n = 689

Surveys began in 1960 and were completed on every visit

   • Number of Cases: 63

In younger men PF predicts a reduced risk of CHD but not LTPA.

  

• Sex: Men

   
  

• Age:

 

After adjusting for coronary risk factors there was:

 

USA

 

51.6 ± 16.8 yr

   
  

• Characteristics: Community dwelling

PA assessment: Survey for LTPA (97 activities) at every visit.

RR: 0.53 (p < 0.001) and

In older men, high intensity LTPA and PF appear to be of similar importance in reducing CHD risk.

Prospective cohort

   

RR: 0.61 (p = 0.024) in older men.

 

D & B score = 12

 

• Baltimore Longitudinal Study of Aging

PF assessment: Treadmill VO2 max test on alternate visits

Total LTPA was unrelated to coronary risk in either age group.

 
    

With 3 levels of LTPA intensity substituted for total LTPA:

 
   

Unpaired t-tests and chi square tests. Cox Proportional hazards Analysis

RR = 0.39 for tertile 3 vs. tertile 1

 

Tanasescu et al 2002 [252]

To assess the amount, type and intensity of PA in relation to risk of CHD in men.

• n = 44,452

PA assessment: Questionnaire

   • Number of Cases: 1,700

Total PA, running, weight training, and walking were associated with a reduced risk for CVD.

  

• Sex: Men

   
  

• Age: 40-75 yr

 

Age adjusted HR (95% CI) by total PA

 

USA

 

• Characteristics: Health professionals, no history of CHD and in good health

Total PA (MET hr/wk)

   • Q1 = 1.00 (referent)

 
   

Q1 = 0-6.32

   • Q2 = 0.85 (0.74 0.98)

 

Prospective cohort

  

Q2 = 6.33-14.49

   • Q3 = 0.78 (0.67-0.92)

 
   

Q3 = 14.50-25.08

   • Q4 = 0.72 (0.62-0.83)

The average exercise intensity was associated with a reduced risk (independent of total PA).

   

Q4 = 25.09-41.98

   • Q5 = 0.58 (0.49-0.68)

 

D & B score = 11

  

Q5 = > 41.99

p = .001

 
  

• Health Professionals follow-up study

Exercise intensity (METs)

Age adjusted HR (95% CI) by exercise intensity

 
   

G1 = Low-1-4

   • G1 = .00 (referent)

 
   

G2 = Mod.-4-6

   • G2 = 0.94 (0.83-1.04)

 
   

G3 = High 6-12

  
   

Walking pace independent of total volume of PA (mph)

   • G3 = 0.83 (0.72-0.97)

 
    

p = 0.02

 
   

Q1 = <2

Age adjusted HR (95% CI) by walking pace

 
   

Q2 = 2-3

   • Q1 = 1.00 (referent)

 
   

Q3 = 3-4

   • Q2 = 0.72 (0.54-0.94)

 
   

Q4 = > 4

   • Q3 = 0.61 (0.45-0.81)

 
    

   • Q4 = 0.51 (0.31-0.84)

 
   

Outcome Measure: Nonfatal MI or Fatal CHD occurring during follow-up

p <0.001

 
   

Cox proportional HR

  

Vatten et al 2006 [253]

To investigate whether obesity- related CV mortality could be modified by PA.

• n = 54,284 (27,769 men; 26,515 women)

Length of Follow-up: 16 years

   • Number of Cases: 2,462

Increased PA reduces the risk of death in women, but not in men.

    

Multivariate HR (95% CI), men

 

Norway

 

• Sex: Men and women

PA assessment:

   • Q1 = 1.00 (referent)

 
   

Questionnaire

   • Q2 = 1.01 (0.89-1.16)

 

Prospective cohort

 

Age: ≥ 20 yr

Divided into 4 groups

   • Q3 = 0.98 (0.84-1.14)

 
  

• Characteristics: Free from CVD at baseline

Q1 = High

   • Q4 = 1.18 (1.00-1.38)

 
   

Q2 = Medium

p = 0.11

 

D & B score = 12

  

Q3 = Low

  
  

• HUNT study

Q4 = Never

Multivariate HR (95% CI), women

 
   

Outcome Measure: Ischemic heart disease mortality

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 1.23 (1.01-1.51)

 
    

   • Q3 = 1.54 (1.24-1.91)

 
    

   • Q4 = 1.52 (1.23-1.88)

 
   

Cox proportional HR

p <0.001

 

Wagner et al 2002 [254]

To investigate if the association between PA patterns and incidence of coronary events could explain the gradient in CHD observed between 2 countries.

• n = 9,758

Length of Follow-up: 5 yrs

Number of Cases: 167 hard CHD, 154 angina events

Beneficial effect of LTPA EE on hard CHD incidence in middle aged men.

  

• Sex: Men and women

PA assessment: Questionnaire for LTPA, 3 groups:

Number of Dropouts: < 2%

 

Ireland/France

 

• Age: 50-59 yr

   
  

• Characteristics: Healthy at Baseline

 

HR (95% CI), hard events

 

Prospective cohort

  

G1 = Lowest

   • G1 = 1.00 (referent)

 
   

G2 = Middle

   • G2 = 0.73 (0.51-1.05)

 
   

G3 = Highest

   • G3 = 0.66 (0.46-0.96)

 

D & B score = 12

  

Outcome Measure: CHD hard events and Angina

p = 0.04

 
    

HR (95% CI), angina

 
    

   • G1 = 1.00 (referent)

 
   

Cox proportional HR

   • G2 = 0.83 (0.55-1.25)

 
    

   • G3 = 1.28 (0.88-1.86)

 
    

p = 0.10

 

D & B score, Downs and Black quality score; YR, years; G, groups; CHD, coronary heart disease; RR, risk ratio; 95% CI, 95% confidence interval; PA, physical activity; VPA, vigorous physical activity; CV, cardio vascular; MET, metabolic equivalent; kcal/wk, kilocalories per week; Q, quartile or quintile; km/h, kilometers per hour; LTPA, leisure-time physical activity; HR, hazard ratio; OPA, occupational physical activity; kcal/kg/day kilocalories per kilogram per day; MI, myocardial infarction; ECG, electrocardiogram; kcal/kg/h kilocalories per kilogram per hour; mph, miles per hour; CVD, cardiovascular disease.

Similar to the all-cause mortality data, the risk for cardiovascular disease demonstrates a graded inverse dose-response relationship to physical activity and fitness. The relative reduction in the incidence of cardiovascular disease averages 33% (median risk reduction of 36%), with greater risk reductions in studies that employed objective measures of aerobic fitness. It is not uncommon for studies to demonstrate a 50% or higher risk reduction when an objective measure of physical fitness was taken (Table 12). The importance of physical activity may actually be underestimated owing to multivariate control for many confounding factors (as discussed previously) and the fact that effects of within-person variation in physical activity are often not considered [55]. The relative risk reduction appears to be similar for men and women, and also appear to extend to non-Caucasian populations [56]. Some evidence also exists indicating that small amounts of physical activity are associated with lower cardiovascular-disease related mortality [57, 58]. Similar to all-cause mortality, physical activity confers health benefits independent of other known risk factors [42, 59]. Collectively, the level of evidence would be considered to be Level 2A based on the presence of overwhelming evidence from observational trials. The quality of the investigations was generally high with a mean (and median) Downs and Black score of 12 (range 9-14).

Implications

Research in the field began with the landmark work of Morris and colleagues, which demonstrated that men in physically demanding occupations (bus conductors and postmen) had a significantly lower risk of heart disease than individuals who worked in less demanding jobs (bus drivers and office workers) [45]. Since then considerable research has examined the relationship between physical activity and the risk for cardiovascular disease. In fact, several systematic reviews of the literature have been developed regarding the role of habitual physical activity in the primary and secondary prevention of cardiovascular disease [33, 6062]. The research to date has been consistent and compelling, habitual physical activity reduces markedly the risk for cardiovascular disease.

Based on the available literature, there is compelling evidence that the recommendation of 30 min of moderate intensity exercise on most days of the week (equivalent to 4.2 MJ/wk or 1000 kcal/wk) reaches a threshold associated with significant reductions in cardiovascular-related mortality [32, 63]. Brisk walking has also been shown to be preferable to a slower pace [64]. However, weekly exercise volumes of less than 4.2 MJ (1000 kcal) may be cardio-protective [14, 59, 6567]. For instance, Lee et al. (2001) found that as little as 1 hr/wk of walking was associated with a 50% lower cardiovascular disease mortality in one sample of women. Wisloff et al. [58] reported that a single weekly bout of self-reported high intensity exercise was associated with a lower risk of cardiovascular death relative to those reporting no activity in both men (RR = 0.61, 95% CI = 0.49-0.75), and women (RR = 0.49, 95% CI = 0.27-0.89). Moreover, no additional benefit was seen with higher durations or frequency of exercise sessions [58]. The authors stated that this evidence challenges "current recommendations that require at least 1000 kcal of caloric expenditure per week to achieve exercise-induced protection against premature cardiovascular death." However, this research is in fact supportive of the Canadian guidelines which recognize the potential health benefits of low volumes of physical activity as reflected by the statement "Every little bit counts, but more is even better - everyone can do it!" It however should be noted that the statement "more is even better" is supported by a strong evidence base.

Recommendation #2

For a reduced risk for cardiovascular disease-related events and mortality, it is recommended that individuals participate in 30 min or more of moderate to vigorous exercise on most days of the week. Greater health benefits appear to occur with high volume and/or intensities of activity. Health benefits may also occur with as little as one hr of brisk walking per week. [Level 2, Grade A]

The Primary Prevention of Stroke

Stroke affects a significant proportion of Canadian society with approximately 50,000 new cases each year [68]. The relationship between physical activity and the risk for stroke is compelling, supporting at least a 25-30% risk reduction in the most active individuals [31]. In fact, in a review of the literature Katzmarzyk and Janssen [20] reported that lack of physical activity carried a relative risk of 1.60 (95% CI = 1.42-1.80) for stroke, similar to or higher than that for coronary heart disease (1.45), hypertension (1.30), colon cancer (1.41), breast cancer (1.31), type 2 diabetes (1.50), and osteoporosis (1.59).

In our systematic review of the literature, a total of 1104 citations were identified during the electronic database search (Figure 5). Of these citations, 405 were identified in MEDLINE, 183 in EMBASE, 227 in Cochrane, and 289 in the CINAHL/SportDiscus/PsychInfo search. A total of 13 duplicates were found, leaving a total of 1091 unique citations. A total of 1011 articles were excluded after scanning, leaving a total of 80 articles for full review. An additional 9 articles were retrieved through cross-referencing and the authors' knowledge of the field. From these articles 64 were excluded after full review leaving 25 articles for inclusion in the systematic review. The reasons for exclusion included non-experimental/weak design (poor execution introducing bias) (n = 16), did not contain three levels of physical activity or not possible to determine dose-response relationship (n = 14), reviews, summaries, meta-analyses (n = 17), dissertations, thesis, abstracts (n = 8), and other (n = 9). Therefore, a total of 25 articles were included in the systematic review of the literature regarding the relationship between physical activity and the primary prevention of stroke (Table 13).
https://static-content.springer.com/image/art%3A10.1186%2F1479-5868-7-39/MediaObjects/12966_2009_Article_345_Fig5_HTML.jpg
Figure 5

Results of the Literature Search for Stroke.

Table 13

Studies examining the relationship between physical activity and stroke.

Publication Country Study Design Quality Score

Objective

Population

Methods

Outcome

Comments and Conclusions

Wisloff et al 2006 [58]

To assess exercise amount and intensity in relation to subsequent CVD mortality (including stroke).

• n = 27,143 men, 28,929 women

16 year follow up

Multivariate adjusted RR (95% CI) Men

Both high and low- intensity exercise may be associated with a reduced risk of stroke in both men and women.

Norway

 

• Sex: Men and women

PA Assessment: Questionnaire

G1 = 1.00 (referent)

 
  

• Age: ≥ 20 yr

 

G2 = 0.90 (0.70-1.17)

 
  

• Characteristics: free from CVD

PA

G3a = 0.90 (0.64-1.26)

 
  

• HUNT Study

G1 = None

G3b = 0.59 (0.27-1.27)

 
   

G2 = <1/wk

G3c = 0.62 (0.40-0.95)

 
   

G3a = 1/wk ≤ 30 min low

G3d = 0.51 (0.31-0.86)

 
   

G3b = 1/wk ≤ 30 min high

G4a = 0.72 (0.49-1.05)

 
   

G3c = 1/wk > 30 min low

G4b = 0.63 (0.31-1.30)

 

Prospective cohort

  

G3d = 1/wk > 30 min high

G4c = 1.02 (0.72-1.44)

 
   

G4a = 2-3/wk ≤ 30 min low

G4d = 0.59 (0.37-0.92)

 
   

G4b = 2-3/wk ≤ 30 min high

G5a = 0.97 (0.70-1.36)

 

D & B score = 12

  

G4c = 2-3/wk > 30 min low

G5b = 0.68 (0.27-1.66)

 
   

G4d = 2-3/wk > 30 min high

G5c = 0.81 (0.65-1.20)

 
   

G5a = ≥ 4/wk ≤ 30 min low

G5d = 0.67 (0.49-1.11)

 
   

G5b = ≥ 4/wk ≤ 30 min high

  
   

G5c = ≥ 4wk > 30 min low

RR (95% CI) Women

 
   

G5d = ≥ 4/wk > 30 min high

G1 = 1.00 (referent)

 
   

Outcome Measure: IHD mortality

G2 = 1.01 (0.81-1.25)

 
   

Cox proportional HR

G3a = 0.88 (0.68-1.15)

 
    

G3b = 0.98 (0.46-2.10)

 
    

G3c = 0.63 (0.42-0.94)

 
    

G3d = 1.00 (0.50-1.98)

 
    

G4a = 0.91 (0.70-1.17)

 
    

G4b = 1.44 (0.78-2.65)

 
    

G4c = 0.62 (0.44-0.88)

 
    

G4d = 0.77 (0.36-1.66)

 
    

G5a = 0.74 (0.56-0.99)

 
    

G5b = 0.40 (0.10-1.62)

 
    

G5c = 0.63 (0.45-0.89)

 
    

G5d = 0.51 (0.21-1.26)

 

Abbott et al 2003 [69]

To examine the way in which risk factor effects on the incidence of thromboembolic and hemorrhagic stroke can change over a broad range of ages.

• n = 7,589

6, 15 and 26 year follow up

Incidence rates per 1000 of stroke:

The protective effect of PA on reducing risk of stroke increased with age.

USA

 

• Sex: Men

 

   • G1 = 9.0 (49)

 
  

• Age: 45-93 yr

PA assessment: Using PA index over a 24 hour period PA information collected at study enrolment 1965-1968 and updated at physical examinations that occurred at 6, 15 and 26 years into follow-up.

   • G2 = 17.8 (124)

 

Prospective cohort

 

• Characteristics: Free from CHD and stroke at enrolment; Japanese ancestry living on the island of Oahu, Hawaii.

Grouped into 4 age groups, yr:

   • G3 = 33.4 (112)

 

D & B score = 14

 

• Honolulu Heart Program

G1 = 45-54

   • G4 = 48.1 (111)

 
   

G2 = 55-64

Incidence of stroke event increased with advancing age p <0.001

 
   

G3 = 65-74

There appeared to be a small protective effect within each age group. Inverse relations increased with age (p = 0.046). The protective effect of PA became significant in men >77 years (p = 0.032)

 
   

G4 = 75-93

  
   

Outcome Measure: diagnosis of fatal and non fatal stroke during 26 years of follow-up

  
   

Cox proportional HR

  

Gillium et al 1996 [70]

To examine the relationship between recreational and non-recreational PA and risk of stroke.

• n = 2,368 men, 2,713 women

11.6 year follow up

Number of Cases: 249 white women, 270 white men, 104 black

Sedentary behaviour was found to be associated with increased risk of stroke.

USA

 

• Sex: Men and women

PA assessment: Questionnaire divided into tertiles:

  
  

• Age: 45-74 yr

T1 = Low

RR (95% CI) Black men and women Recreational PA

 

Prospective cohort

 

• Ethnicity: Black and white

T2 = Medium

   • T1 = 1.33 (0.67-2.63)

 

D & B score = 12

 

• NHANES I

T3 = High

   • T2 = 1.33 (0.63-2.79)

 
    

   • T3 = 1.00 (referent)

 
   

Outcome Measure: Total Stroke

Non-recreational PA

 
   

Cox proportional HR

   • T1 = 1.40 (0.90-2.16)

 
    

   • T2 = 1.41 (0.74-2.70)

 
    

   • T3 = 1.00 (referent)

 
    

RR (95% CI) White men age 45-64 Recreational PA

 
    

   • T1 = 1.24 (0.63-2.41)

 
    

   • T2 = 1.17 (0.61-2.27

 
    

   • T3 = 1.00 (referent)

 
    

Non-recreational PA

 
    

   • T1 = 1.07 (0.40-2.86)

 
    

   • T2 = 1.75 (1.04-2.96)

 
    

   • T3 = 1.00 (referent)

 
    

RR (95% CI) White women age 45-64 Recreational PA

 
    

   • T1 = 3.13 (0.95-10.32)

 
    

   • T2 = 1.80 (0.52-6.22)

 
    

   • T3 = 1.00 (referent)

 
    

Non-recreational PA

 
    

   • T1 = 3.51 (1.66-7.46)

 
    

   • T2 = 1.07 (0.57-1.99)

 
    

   • T3 = 1.00 (referent)

 
    

RR (95% CI) White men age 65-74 Recreational PA

 
    

   • T1 = 1.29 (0.58-1.88)

 
    

   • T2 = 0.86 (0.58-1.28)

 
    

   • T3 = 1.00 (referent)

 
    

Non-recreational

 
    

   • T1 = 1.82 (1.15-2.88)

 
    

   • T2 = 1.20 (0.88-1.64)

 
    

   • T3 = 1.00 (referent)

 
    

RR (95% CI) White women age 65-75 Recreational PA

 
    

   • T1 = 1.55 (0.95-2.53)

 
    

   • T2 = 1.27 (0.76-2.12)

 
    

   • T3 = 1.00 (referent)

 
    

Non-recreational PA

 
    

   • T1 = 1.82 (1.10-3.02)

 
    

   • T2 = 1.42 (1.01-2.00)

 
    

   • T3 = 1.00 (referent)

 

Lee and Blair 2002 [71]

To examine the association between PF and stroke mortality in men.

• n = 16,878

Baseline medical evaluation between 1971 and 1994 with average follow up period of 10 years

Average estimated maximal METs

Moderate and high levels of PF were associated with lower risk of stroke mortality in men.

  

• Sex: Men

 

   • T1 = 8.5 MET

 
  

• Age: 40-87 yrs

 

   • T2 = 10.5 MET

 

USA

 

• Aerobics Center Longitudinal Study

 

   • T3 = 13.1 MET

 

Prospective cohort

  

PF assessment: Maximal exercise tolerance test, divided into tertiles

RR (95% CI) adjusted for age and exam year

 
    

   • T1 = 1.00 (referent)

 

D & B score = 13

  

T1 = Low

   • T2 = 0.35 (0.16-0.77)

 
   

T2 = Moderate

   • T3 = 0.28 (0.11-0.71)

 
   

T3 = High

Trend p = 0.005

 
   

Cox proportional HR

  

Hu et al 2000 [72]

To examine the association between PA and risk of total stroke and stroke sub- types in women.

• n = 72,488

Baseline measurement in 1986 with follow-up questionnaire in 1988 and 1992

• 407 cases of stroke (258 ischemic strokes, 67 subarachnoid hemorrhages, 42 intracerebral hemorrhages, and 40 strokes of unknown type)

PA, including moderate-intensity exercise such as walking, is associated with a substantial reduction in risk of total and ischemic stroke in a dose- response manner.

  

• Sex: Women

   
  

• Age:40-65 yr

   

USA

 

• Characteristics: Nurses

   

Prospective cohort

 

• Nurses' Health Study

PA assessment: Questionnaire for total PA (MET h/wk), divided into quintiles, walking activity (MET h/wk), divided into quintiles and walking pace

Multivariate RR (95% CI) for total stroke by total PA level

 
    

   • Q1 = 1.00 (referent)

 

D & B score = 13

   

   • Q2 = 0.98

 
    

   • Q3 = 0.82

 
    

   • Q4 = 0.74

 
    

   • Q5 = 0.66

 
   

Total PA (MET h/wk)

  
    

p = 0.005

 
   

Q1 = 0 - 2.0

  
   

Q2 = 2.1 - 4.6

  
    

Multivariate RR (95% CI) for ischemic Stroke by total PA level

 
   

Q3 = 4.7 - 10.4

  
   

Q4 = 10.5-21.7

  
    

   • Q1 = 1.00 (referent)

 
   

Q5 = > 21.7

  
    

   • Q2 = 0.87

 
   

Walking activity (MET h/wk)

   • Q3 = 0.83

 
   

Q1 = 0.5

   • Q4 = 0.76

 
   

Q2 = 0.6 - 2.0

   • Q5 = 0.52

 
   

Q3 = 2.1 - 3.8

p = 0.003

 
   

Q4 = 3.9 - 10

  
   

Q5 = 10

Multivariate RR (95% CI) for total stroke by walking activity

 
   

Walking pace (mph)

   • Q1 = 1.00 (referent)

 
   

G1 < 2.0

   • Q2 = 0.76

 
   

G2 = 2-2.9

   • Q3 = 0.78

 
   

G3 3.0

   • Q4 = 0.70

 
    

   • Q5 = 0.66

 
   

Outcome measure: Stroke incidence

p = 0.01

 
    

Multivariate RR (95% CI) for ischemic stroke by walking activity

 
   

Pooled logistic regression

  
   

Cox proportional HR

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 0.77

 
    

   • Q3 = 0.75

 
    

   • Q4 = 0.69

 
    

   • Q5 = 0.60

 
    

p = 0.02

 
    

Multivariate RR (95% CI) for total stroke by usual Walking Pace

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.81

 
    

   • G3 = 0.49

 
    

p < 0.001

 
    

Multivariate RR (95% CI) for ischemic stroke by usual walking pace

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.71

 
    

   • G3 = 0.47

 
    

p < 0.001

 

Lee et al 1999 [74]

To examine the association between exercise and stroke risk.

• n = 21,823

11.1 year follow up

Number of Cases: 533

VPA is associated with a decreased risk of stroke in men.

  

• Sex: Men

   
  

• Age: 40-84 yr

PA assessment: Questionnaire for frequency of VPA, divided into 4 groups

Multivariate RR1 (95% CI) for total stroke by VPA

 

USA

     
    

   • G1 = 1.00 (referent)

 

Prospective cohort

   

   • G2 = 0.79 (0.61-1.03)

Inverse association with PA seemed to be mediated through beneficial effects on body weight, BP, cholesterol and glucose tolerance.

   

G1 < 1 time/week

   • G3 = 0.80 (0.65-0.99)

 
   

G2 = 1 time/week

   • G4 = 0.79 (0.61-1.03)

 

D & B score = 13

  

G3 = 2-4 times/week

p = 0.04

 
   

G4 ≥ 5 times/week

RR2 (95% CI) for total stroke by VPA

 
    

   • G1 = 1.00 (referent)

 
   

RR1 = adjusted for smoking, alcohol consumption, history of angina and parental history of MI at <60 years

   • G2 = 0.81 (0.61-1.07)

 
    

   • G3 = 0.88 (0.70-1.10)

 
    

   • G4 = 0.86 (0.65-1.13)

 
    

p = 0.25

 
    

RR2 (95% CI) for ischemic stroke by

 
   

RR2 = adjusted for all of the above plus, BMI, history of, hypertension, high cholesterol and diabetes

  
    

VPA

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.90 (0.66-1.22)

 
    

   • G3 = 0.95 (0.74-1.22)

 
    

   • G4 = 0.97 (0.71-1.32)

 
   

Outcome Measure: Total Stroke (Ischemic and Hemorrhagic)

p = 0.81

 
    

RR2 (95% CI) for hemorrhagic stroke by VPA

 
   

Cox proportional HR

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.54 (0.25-1.13)

 
    

   • G3 = 0.71 (0.41-1.23)

 
    

   • G4 = 0.54 (0.26-1.15)

 
    

p = 0.10

 

Bijnen et al 1998 [166]

To describe the association between the PA patterns of elderly men and stroke mortality.

• n = 802

10 year follow up

Number of Cases: 47

No significant finding

  

• Sex: Men

   
  

• Age:64-84 yr

PA assessment:

Multivariate adjusted RR (95% CI)

 

Denmark

 

• Characteristics: Not all free from previous stroke

Questionnaire for LTPA, divided into tertiles

   • T1= 1. 00 (referent)

 
    

   • T2 = 0.65 (0.33-1.25)

 

Prospective cohort

  

T1 = Lowest

   • T3 = 0.55 (0.24-1.26)

 
   

T2

p = 0.12

 
   

T3 = Highest

  

D & B score = 15

     
   

Outcome Measure: Stroke Mortality

  
   

Cox proportional HR

  

Schnohr et al 2006 [214]

To describe the association between different levels of LTPA and subsequent causes of death (stroke).

• n = 2136 men, 2,758 women

5 year follow up

RR (95% CI), univariate

Although RR for of death from stroke was below 1 for both moderate and high compared with low PA, this association did not reach the level of statistical significance.

    

   • G1 = 1.00 (referent)

 
  

• Sex: Men and women

PA assessment:

   • G2 = 0.64 (0.39-1.05)

 

Copenhagen

 

• Age: 20 -- 79 yr

Questionnaire for LTPA,

   • G3 = 0.70 (0.41-1.21)

 
  

• Characteristics: Healthy, PA level did not change between 2 examinations, 5 years apart

divided into 3 groups

Trend p = 0.4

 

Prospective cohort

  

G1 = Low PA (<4 METS)

  
   

G2 = Moderate PA (4-6

RR (95% CI), multivariate:

 
   

METS)

   • G1 = 1.00 (referent)

 

D & B score = 13

  

G3 = High PA (>6 METS)

   • G2 = 0.67 (0.40-1.12)

 
  

• Copenhagen City Heart Study

 

   • G3 = 0.76 (0.43-1.34)

 
   

Multivariate Analysis Kaplan-Meier Plots

Trend p = 0.6

 
   

Linear, Logistical and Cox Regression.

  

Vatten et al 2006 [253]

To investigate whether obesity- related CV mortality could be modified by PA.

• n = 26,515 men, 27,769 women

16 year follow up

Number of Cases: 994 women, 771 men

Lower levels of TPA are associated with an increased risk of stroke.

  

• Sex: Men and women

PA assessment: Questionnaire for total amount of PA, divided into 4 groups

  

Norway

 

• Age: 20 yr

 

Multivariate HR (95% CI), men

 
  

• Characteristics: Free from CVD at baseline

 

   • Q1 = 1.00 (referent)

 

Prospective cohort

   

   • Q2 = 1.05 (0.85-1.30)

 
  

• HUNT study

G1 = High

   • Q3 = 1.21 (0.95-1.54)

 
   

G2 = medium

   • Q4 = 1.35 (1.05-1.74)

 

D & B score = 14

  

G3 = low

p = 0.009

 
   

G4 = never

  
    

Multivariate HR (95% CI), women

 
   

Outcome Measure: Stroke mortality

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 1.16 (0.93-1.45)

 
    

   • Q3 = 1.45 (1.14-1.86)

 
   

Cox proportional HR

  
    

   • Q4 = 1.45 (1.14-1.83)

 
    

p < 0.001

 

Agnarsson et al 1999 [255]

To examine the association of LTPA and pulmonary function with the risk of stroke.

• n = 4,484

Length of Follow-up: 10.6 ± 3.6 years

Number of Cases: 249

Apparent protective effect of regular continued LTPA in middle age men on the risk of ischemic stroke.

  

• Sex: Men

   
  

• Age: 45-80

 

Adjusted for age and smoking RR (95% CI) for total stroke by LTPA level

 

Iceland

 

• Characteristics: no history of Stroke

PA assessment: Questionnaire for LTPA (h/wk) and type of activity (intensity), each divided into 3 groups

  

Prospective cohort

 

• Reykjavik Study

 

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.84 (0.63-1.13)

 
    

   • G3 = 0.73 (0.40-1.35)

 

D & B score = 13

  

LTPA summer/winter

  
   

G1 = none

Adjusted for age and smoking RR (95% CI) for ischemic stroke by LTPA level

 
   

G2 = ≤ 5 h/wk

  
   

G3 = ≥ 6 h/wk

  
    

   • G1 = 1.00 (referent)

 
   

Type of Activity

   • G2 = 0.72 (0.51-1.01)

 
   

G1 = none

  
    

   • G3 = 0.78 (0.41-1.48)

 
   

G2 = low intensity

  
   

G3 = high Intensity

  
    

RR (95% CI) for total stroke by type of activity

 
   

Outcome Measure: Total and ischemic Stroke

   • G1 = 1.0,0 (referent)

 
    

   • G2 = 0.75 (0.53-1.08)

 
    

   • G3 = 1.10 (0.78-1.57)

 
   

Cox proportional HR

  
    

RR (95% CI) for ischemic stroke by type of activity

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.72 (0.44-1.07)

 
    

   • G3 = 0.96 (0.64-1.44)

 

Ellekjaer et al 2000 [256]

To examine the association between different levels of LTPA and stroke mortality in middle-aged and elderly women.

• n = 14,101

Baseline 1984-1986: 2 self administered questionnaires and clinical measurements included in the screening program.

Number of cases: 457

This study demonstrates a consistent, negative association between PA and stroke mortality in women.

  

• Sex: Women

   
  

• Age: 50 yr

 

Multivariate RR (95% CI), all age groups

 

Norway

 

• Characteristics: free from stroke at baseline

   
    

   • G1 = 1.00 (referent)

 

Prospective cohort

   

   • G2 = 0.77

 
   

PA assessment: Questionnaire for LTPA, divided into 3 groups

   • G3 = 0.52

 

D & B score = 14

   

Multivariate RR (95% CI), age 50--69 years

 
   

G1 = low

 

The most active women had approx. 50% lower risk of death from stroke compare to inactive women.

   

G2 = medium

   • G1 = 1.00 (referent)

 
   

G3 = high

   • G2 = 0.57

 
    

   • G3 = 0.42

 
   

Outcome Measure: Death from stroke

p = 0.0021

 
    

Multivariate RR (95% CI), age 70-79 years

 
   

Cox proportional HR

  
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.79

 
    

   • G3 = 0.56

 
    

p = 0.0093

 
    

Multivariate RR (95% CI), age 80-101 years

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.91

 
    

   • G3 = 0.57

 
    

p = 0.1089

 

Evenson et al 1999 [257]

To examine the relationship between PA and ischemic stroke risk.

• n = 14,575

7.2 year follow up

Number of Cases: 189

PA was weakly associated with a reduced risk of ischemic stroke among middle aged adults.

  

• Sex: Men and women

 

Number of Dropouts: 0%

 
  

• Age: 45-64 yr

PA assessment: Questionnaire (Baecke questionnaire)

  

USA

 

• Atherosclerosis Risk in Communities Study

 

Sport, Incidence of Ischemic Stroke

 

Prospective cohort

   

Multivariate adjusted RR (95% CI) by sport

 
   

Outcome Measure:

  
   

Ischemic Stroke

   • Q1 = 1.00 (referent)

 

D & B score = 14

   

   • Q3= 0.83 (0.52-1.32)

 
   

Multivariate Poisson and Cox proportional HR

  
    

Multivariate adjusted RR (95% CI) by LTPA

 
    

   • Q1 = 1.00 (referent)

 
    

   • Q2 =

 
    

   • Q3 = 0.89 (0.57-1.37)

 
    

Multivariate adjusted RR (95% CI) by OPA

 
    

   • Q1 = 1.00 (referent)

 
    

   • Q2 =

 
    

   • Q3 = 0.69 (0.47-1.00)

 

Haheim et al 1993 [258]

To determine the risk factors of stroke incidence and mortality.

• n = 14,403

Baseline Screening from May 1972- December 1973.

HR (95% CI) for stroke incidence

Increased LTPA is associated with a reduced risk of stroke incidence but not mortality.

  

• Sex: Men

 

   • G1 = 1.00 (referent)

 
  

• Age: 40-49 yr

 

   • G2 = 0.64 (0.38-1.08)

 

Norway

  

PA assessment: Questionnaire for LTPA, divided into groups

   • G3 = 0.36 (0.15-0.80)

 

Prospective cohort

   

HR (95% CI) for stroke mortality

 
   

G1 = Sedentary

   • G1 = 1.00, (referent)

 
   

G2 = Moderate

   • G2 = 0.82 (0.33-2.35)

 

D & B score = 14

  

G3 = Intermediate or Great

   • G3 = 0.29 (0.03-1.51)

 
   

Outcome Measure: Incidence of stroke morbidity and mortality until study end date, December 31, 1984.

  
   

Cox proportional HR

  

Hu et al 2005 [259]

To assess the relationship of different types of PA with total and type-specific stroke risk.

• n = 47,721

PA assessement: Mailed questionnaire for LTPA, OPA and commuting PA, divided into groups as follows:

RR (95% CI) by LTPA, men

A high level of LTPA reduces the risk of all subtypes of stroke. Daily active commuting also reduces the risk of ischemic stroke.

  

• Sex: Men and women

 

   • G1 = 1.00 (referent)

 
    

• G2 = 0.83

 

Finland

 

• Age: 25-64

 

   • G3 = 0.72

 
  

• Characteristics: Healthy at baseline

 

p < 0.001

 

Prospective cohort

     
   

LTPA levels:

RR (95% CI) by LTPA, women

 
   

G1 = Low

   • G1 = 1.00 (referent)

 

D & B score = 13

  

G2 = Moderate

   • G2 = 0.86

 
   

G3 = High

   • G3 = 0.75

 
    

p = 0.007

 
   

OPA:

  
   

G1 = Light

RR (95% CI) by LTPA, men and women

 
   

G2 = Moderate

  
   

G3 = Hard

  
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.85

 
   

Commuting PA:

  
   

G1 = Motorized or no work,

   • G3 = 0.73

 
   

G2 = walking or cycling 1-29 min G3 = walking or cycling ≥ 30 min.

p <0.001

 
    

RR (95% CI) by OPA, men

 
    

• Not significant

 
   

Outcome Measure: Incidence of fatal or non-fatal stroke occurring during follow-up until end of 2003. Mean follow-up of 19 years.

  
    

RR (95% CI) by OPA, women

 
    

• Not significant

 
    

RR (95% CI) by OPA, men and women

 
    

   • G1 = 1.00 (referent)

 
   

Cox proportional hazard

   • G2 = 0.90

 
    

• G3 = 0.87

 
    

p = 0.007

 
    

RR (95% CI) by commuting PA, men

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.91

 
    

   • G3 = 0.85

 
    

p = 0.047

 
    

RR (95% CI) by commuting PA, women

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.86

 
    

   • G3 = 0.85

 
    

p = 0.018

 
    

RR (95% CI) by commuting PA, men and women

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.89

 
    

   • G3 = 0.85

 
    

p = 0.002

 

Kiely et al 1994 [260]

To examine the influence of increased PA on stroke risk in members of the Framingham study cohort.

• n = 1,897 men 2,299 women

Baseline measurement in 1954-1955 and follow up in either 1968-1969 or 1971- 1972

Multivariate adjusted RR (95% CI) at first examination, men (mean age 50 years)

Medium and high levels of PA among men are protective against stroke relative to low levels.

  

• Sex: Men and women

   

USA

   

   • G1 = 1.00 (referent)

 
  

• Age: 28-62 yr

 

   • G2 = 0.90 (0.62-1.31) p = 0.59

 

Prospective cohort

 

• Characteristics: Free from stroke

PA assessment: Questionnaire for metabolic work done during a typical 24 hr period, divided into 3 groups

   • G3 = 0.84 (0.59-1.18) p = 0.31

 
    

Multivariate adjusted RR (95% CI) at first examination, women (mean age 50 years)

Protective effect of PA was slightly less for high levels of PA compared to medium levels for older men.

D & B score = 12

     
   

G1 = Low

   • G1 = 1.00 (referent)

 
   

G2 = Medium

   • G2 = 1.21 (0.89-1.63) p = 0.23

 
   

G3 = High

   • G3 = 0.89 (0.60-1.31) p = 0.54

 
   

Outcome Measure: Incidence of stroke, as defined by the first occurrence of atherothrombotic brain infarctions, cerebral embolism or other type of stroke, during 32 years of follow-up.

  
    

Multivariate adjusted RR (95% CI) at second examination, men (mean age 63 years)

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.41 (0.24-0.89) p = 0.0007

 
    

   • G3 = 0.53 (0.34-0.84) p = 0.007

 
    

Multivariate adjusted RR (95% CI) at second examination, women (mean age 64 years)

 
   

Cox proportional HR

  
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.97 (0.64-1.47) p = 0.67

 
    

   • G3 = 1.21 (0.75-1.96) p = 0.43

 

Krarup et al 2007 [261]

To compare the reported level of PA performed during the week preceding an ischemic stroke with that of community controls.

• n = 127 cases 301 controls

PA assessment:

Univariate OR (95% CI)

Stroke patients are less physically active in the week preceding an ischemic stroke when compared to age and sex-matched controls. Increasing PASE score was inversly, log-linearly and significantly associated with OR for ischemic stroke.

   

Questionnaire about PA 1 week prior to stroke (cases) and 1 week prior to questionnaire (controls), divided into PASE scores and quartiles

PASE Score

 
  

• Sex: Men and women

 

   • Q1 = 1.00 (referent)

 

Denmark

   

   • Q2 = 0.51 (0.28-0.95)

 
  

• Age: ≥ 40 yr

 

• Q3 = 0.27 (0.14-0.54)

 

Case control

 

• Characteristics: Case: Stroke Patients (20% had history of Stroke), Controls: 4% had history of stroke

 

• Q4 = 0.08 (0.03-0.20)

 

D & B score = 14

  

Q1 = 0-49

Multivariate OR (95% CI) PASE Score

 
   

Q2 = 50-99

  
   

Q3 = 100-149

   • Q1 = 1.00 (referent)

 
   

Q4 = 150+

   • Q2 = 0.53 (0.26-1.08)

 
    

   • Q3 = 0.27 (0.12-0.59)

 
   

Outcome measure:

  
   

Ischemic stroke

   • Q4 = 0.09 (0.03-0.25)

 
   

Chi squared Kruskal-Wallis Statistics Multivariate conditional logistic regression

  

Kurl et al 2003 [262]

To examine the relationship of PF with subsequent incidence of stroke. Also to compare PF with conventional risk factors as a predictor for future stroke.

• n = 2,011

Baseline examinations conducted between March 1984 and December 1989 with average follow up period of 11 years

Multivariate HR (95% CI), any stroke

Low PF was associated with an increased risk of any stroke and ischemic stroke.

  

• Sex: Men

 

   • Q1 = 1.00 (referent)

 
  

• Age: 42, 48, 54 or 60 yrs

 

   • Q2 = 1.39 (0.70-2.77)

 

Finland

   

   • Q3 = 1.32 (0.66-2.65)

 
  

• Characteristics: Free from stroke or pulmonary disease

• Kuopio Ischaemic Heart Disease Risk Factor Study

 

   • Q4 = 2.30 (1.18-4.06)

 

Prospective cohort

   

Trend p = 0.01

 
   

PF assessment: Maximal exercise test on cycle ergometer. VO2 max (ml/kg/min) divided into quartiles

  
    

Multivariate HR (95% CI), ischemic stroke

 

D & B score = 14

     
    

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 1.28 (0.56-2.94)

 
    

   • Q3 = 1.64 (0.74-3.65)

 
   

Q1 = >35.3

  
    

   • Q4 = 2.40 (1.09-5.25)

 
   

Q2 = 30.3-35.3

  
    

Trend p = 0.01

 
   

Q3 = 25.2-30.2

  
   

Q4 = <25.2

  
   

Outcome Measure: Stroke incidence

  
   

Cox proportional HR

  

Myint et al 2006 [263]

To examine the association between a combination of OPA and LTPA with risk of subsequent stroke.

• n = 22,602

Baseline measurement in

Model A: Used all 4 categories of PA

Higher levels of PA assessed using a single simple pragmatic tool based on both OPA and LTPA is associated with reduced stroke risk.

  

• Sex: Men

1993-1997

HR (95% CI), men and women

 
  

• Age: 40-79 yr

 

   • G1 = 1.00 (referent)

 

UK

 

• Characteristics: Healthy at baseline

PA assessment: Questionnaire for PA (includes LTPA and OPA) divided into 4 groups

   • G2 = 0.78 (0.61-1.00)

 
    

   • G3 = 0.66 (0.49-0.91)

 

Prospective cohort

 

• European Prospective Investigation in Cancer-Norfolk

 

   • G4 = 0.70 (0.49-0.99)

 
    

p = 0.024

 

D & B score = 11

  

G1 = Inactive

HR (95% CI), men

 
   

G2 = moderately inactive

   • G1 = 1.00 (referent)

 
   

G3 = moderately active

   • G2 = 0.75 (0.52-1.09)

 
   

G4 = active

  
    

   • G3 = 0.55 (0.35-0.86)

 
    

   • G4 = 0.67 (0.43-1.05)

 
   

Outcome Measure: Incidence of fatal and non fatal stroke.

  
    

p = 0.41

 
    

Women not significant p = 0.50

 
   

Cox proportional HR

  
    

Model B: Used 3 categories of PA (G3 and G4 combined combined)

 
    

HR (95% CI), men and women

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.78 (0.61-1.00)

 
    

   • G3 = 0.68 (0.52-0.88)

 
    

p = 0.009

 
    

HR (95% CI), men

 
    

   • G1 = 1.00 (referent)

 
    

   • G2 = 0.75 (0.52-1.09),

 
    

   • G3 = 0.61 (0.43-0.86)

 
    

p = 0.019

 
    

Women not significant p = 0.34

 

Noda et al 2005 [264]

To examine the impact of exercise on CVD (stroke) mortality in Asian populations.

• n = 31,023 men, 42,242 women

9.7 year follow up

Number of Cases: 186 men, 141 women

PA through walking and sports participation may reduce the risk of mortality from ischemic stroke

  

• Sex: Men and women

PA assessment: Questionnaire for PA (walking and sports participation (h/day), divided into quartiles:

Number of Dropouts: 3.4%

 

Japan

 

• Age: 40 -79 yr

   
  

• Ethnicity: Asian

 

Multivariate adjusted HR (95% CI) by duration of walking PA, men

 

Prospective cohort

     
    

   • Q1 = 1.03 (0.63-1.69)

 
   

Q1 = <0.5

   • Q2 = 1.00 (referent)

 

D & B score = 13

  

Q2 = 0.5

   • Q3 = 0.56 (0.35-0.91)

 
   

Q3 = 0.6-0.9

   • Q4 = 0.71 (0.49-1.02)

 
   

Q4 = >1.0

  
    

Multivariate adjusted HR (95% CI) by duration of walking PA, women

 
   

Outcome Measure: Death from ischemic stroke

  
    

   • Q1 = 1.38 (0.82-2.33)

 
    

   • Q2 = 1.00 (referent)

 
   

Cox proportional HR

  
    

   • Q3 = 0.56 (0.32-0.97)

 
    

   • Q4 = 0.73 (0.48-1.13)

 
    

Multivariate adjusted HR (95% CI) by sport PA, men

 
    

   • Q1 = 1.34 (0.86-2.08)

 
    

   • Q2 = 1.00 (referent)

 
    

   • Q3 = 1.22 (0.66-2.25)

 
    

   • Q4 = 0.84 (0.45-1.57)

 
    

Multivariate adjusted HR (95% CI) by sport PA, women

 
    

   • Q1 = 1.07 (0.64-1.77)

 
    

   • Q2 = 1.00 (referent)

 
    

   • Q3 = 0.62 (0.25-1.58)

 
    

   • Q4 = 0.73 (0.31-1.70)

 

Paganini-Hill and Barreto 2001 [265]

To identify risk factors and preventative measures for stroke in elderly men and women.

• n = 4,722 men, 8,532 women

Baseline survey in 1981- 1982.

Multivariate adjusted RR (95% CI) for total hemorrhagic occlusion by exercise, men

Emphasized role of lifestyle modification in the primary prevention of stroke.

  

• Sex: Men and women

   
   

PA assessment: Questionnaire on amount of hours per day of exercise

   • Q1 = 1.00 (referent)

 

USA

 

Age: 44-101 yr

 

   • Q2 = 0.88

 
  

• Characteristics: no previous history of stroke. Residence of a retirement community in Southern California

 

Q3 = 0.83

 

Prospective cohort

  

G1 = <0.5

  
   

G2 = <0.1

Multivariate adjusted RR (95% CI) for total hemorrhagic occlusion by exercise, women

 
   

G3 = 1+

  

D & B score = 13

     
   

Outcome Measure: Incidence of hemorrhagic occlusion strokes up until December 31, 1998.

   • Q1 = 1.00 (referent)

 
    

   • Q2 = 0.91

 
    

   • Q3 = 0.85

 
   

Poisson Regression 40 year follow up

  

Pitsavos et al 2004 [266]

To investigate the interaction between PA in men with LVH on stroke mortality.

• n = 489

 

Number of cases: 67

PA reduced the risk of stroke in men without LVH.

  

• Sex: Men

   
   

PA assessment: Questionnaire

RR (95% CI)

 

USA

 

• Age: 40-59 yr

 

   • G1 = 1.00 (referent)

 
  

• Characteristics: Those without LVH

G1 = Sedentary

   • G2 = 0.64 (0.45-0.91)

 

Prospective cohort

  

G2 = Moderate

   • G3 = 0.72 (0.51-1.02)

 
  

• Corfu Cohort (Greece) from Seven Countries Study

G3 = Hard

  

D & B score = 12

  

Outcome Measure: Stroke mortality

  
   

Cox proportional HR

  

Sacco et al 1998 [267]

To investigate the association between LTPA and ischemic stroke.

• n = 369 case, 678 control

Case Subjects were recruited during hospitalization, self referral or from monitoring non hospitalized stroke. Controls were eligible if they had never been diagnosed with stroke and were >39 years.

 

LTPA was related to a decreased occurrence of ischemic stroke in elderly, multiethnic, urban subjects.

  

• Sex: Men and women

 

O R (95% CI) for duration of LTPA and stroke

 

USA

     
  

• Age: > 39 yr

 

   • G1 = 1.00 (referent)

 

Case control

 

• Characteristics: Case Subjects: Diagnosed with first cerebral infarction after July 1, 1993. Control Subjects: Never diagnosed with stroke

 

   • G2 = 0.42

 
    

   • G3 = 0.35

 

D & B score = 14

   

   • G4 = 0.31

 
   

PA assessment:

  
   

Questionnaire

  
   

Divided into duration of LTPA (h/wk)

  
  

• Northern Manhattan Stroke Study

   
   

G1 = 0

  
   

G2 = <2

  
   

G3 = 2-<5

  
   

G4 = ≥ 5

  
   

Multivariate conditional logistic regression Baseline data collection from 1982-1983 in East Boston (MA), New Haven (CT) and Iowa and Washington counties (IA).

  

Simonsick et al 1993 [268]

To examine the association between recreational PA among physically capable older adults and incidence of selected chronic diseases and mortality over 3 and 6 years.

• n = 1,815

 

After 3 years Iowa

No consistent relationship between PA and stroke was found after 3 or 6 years across all 3 population cohorts.

  

• Sex: Men and women

   
  

• Age: ≥ 65 yrs

 

OR (95% CI) Stroke and activity level

 

USA

 

• Characteristics: Physically capable to do heavy work around the house, walk up and down a flight of stairs and walk a half mile without help.

 

   • T1 = 0.22 (0.08-0.61)

 
    

   • T2 = 1.05 (0.60-1.84)

 

Prospective cohort

   

   • T3 = 1.00 (Referent)

 
   

PA assessment: Questionnaire

  
    

New Haven

 

D & B score = 12

  

T1 = High

OR (95% CI) Stroke and activity level

 
   

T2 = Moderate and

   • T1 = 1.06 (0.38-2.95)

 
   

T3 = Inactive

   • T2 = 1.26 (0.54-2.92)

 
  

• Established Populations for Epidemiologic Studies of the Elderly

 

   • T3 = 1.00 (Referent)

 
   

Outcome Measure: Stroke incidence during 3 and 6 year follow-ups.

  
    

East Boston

 
    

OR (95% CI) Stroke and activity level

 
    

   • T1 = 0.59 (0.17-1.95)

 
   

Logistic Regression

  
    

   • T2 = 1.08 (0.52-2.27)

 
    

   • T3 = 1.00 (Referent)

 
    

After 6 years

 
    

Iowa

 
    

OR (95% CI) Stroke and activity level

 
    

   • T1 = 0.56 (0.31-1.00)

 
    

   • T2 = 0.97 (0.64-1.48)

 
    

   • T3 = 1.00 (Referent)

 
    

New Haven

 
    

OR (95% CI) Stroke and activity level

 
    

   • T1 = 1.05 (0.52-2.12)

 
    

   • T2 = 1.29 (0.72-2.32)

 
    

   • T3 = 1.00 (Referent)

 
    

East Boston

 
    

OR (95% CI) Stroke and activity level

 
    

   • T1 = 1.21 (0.56-2.61)

 
    

   • T2 = 1.73 (0.98-3.06)

 
    

   • T3 = 1.00 (Referent)

 

Thrift et al 2002 [269]

To examine whether intracerebral hemorrhage is associated with dynamic or static exercise.

• n = 662

PA assessment: Interview, divided into 3 groups: frequency of vigorous activity

Number of Cases: 331

Findings not significant after multivariate analysis.

  

• Sex: Men and women

   
  

• Age: 18-80 yr

 

Multivariate OR (95% CI) by frequency of VPA

 

Australia

 

• Characteristics: Cases: first episode ofintracerebral hemorrhage Controls: Neighbours of cases

   
   

G1 = Never

   • G1 = 1.00 (referent)

 

Case control

  

G2 = Rarely

   • G2 = 0.68 (0.36-1.27)

 
   

G3 = Once or more per month

   • G3 = 0.66 (0.39-1.11)

 

D & B score = 14

   

p = 0.094

 
   

OPA level

Multivariate OR (95% CI) by OPA level

 
   

G1 = Sedentary

   • G1 = 1.00 (referent)

 
   

G2 = Light to moderate

   • G2 = 0.94 (0.59-1.48), p = 0.773

 
   

G3 = Heavy

   • G3 = 1.18 (0.57-2.46), p = 0.650

 
   

Outcome Measure: Intracerebral hemorrhage

  
   

Multiple logistic regression

  

D & B score, Downs and Black quality score; YR, years; wk, week; CVD, cardiovascular disease; G, groups; PA, physical activity; CHD, coronary heart disease; RR, risk ratio; 95% CI, 95% confidence interval; T, tertile; PF, physical fitness; MET, metabolic equivalent; Q, quartile or quintile; OPA, occupational physical activity; LTPA, leisure-time physical activity; HR, hazard ratio; VPA, vigorous physical activity; LVH, left ventricular hypertrophy.

The data providing dose-response information is all observational in nature, involving both case control and cohort investigations. These studies (predominantly prospective cohort designs) included a total of 479,336 participants; averaging 17,753 subjects per study (range 428-73,265). There were a total of 12,361 reported cases of stroke (ranging per study from 32-2,863). The total length of study follow-up for the prospective cohort studies averaged 13.2 yr (ranging from 6-26 yr). The articles were published over a 14 yr period ranging from 1993 to 2007. These studies involved large samples of men and women from regions throughout the world including studies from the USA (11), UK (2), Iceland (1), Denmark (2), Norway (4), Netherlands (1), Finland (2), Japan (1), Australia (1) and Greece (1). Very few studies [69, 70] examined non-Caucasian participants.

We found strong evidence that physical activity was associated with a reduced risk for stroke. The level of evidence was consistent with a Level 3A classification. We observed an average risk reduction of 31% across all studies (median = 29%). In comparison to cardiovascular disease, there was more variability in the risk reductions in stroke in the highest activity/fitness group. The quality of the investigations was also generally quite good with a mean (and median) Downs and Black score of 13 (range 11-15).

The risk reductions appear to be even greater in studies that assessed physical fitness directly. For instance, in data from the Aerobics Center Longitudinal Study [71] the high fitness group (estimated peak METs = 13.1) and the moderate fitness group (estimated peak METs 10.5) had significantly lower risks of stroke mortality (68 and 63%, respectively) than the least fit men (estimated peak METs 8.5).

A dose-response relationship did emerge when examining the literature. However, as illustrated by others this was extremely variable amongst studies and varied according to the type of stroke (ischemic or haemorrhagic) [52]. For instance, 12 studies (46%) revealed a dose-response relationship in one or more measures of occupational and/or leisure-time physical activity and the risk for stroke. It is difficult to determine the minimal and optimal physical activity dosage for the prevention of stroke. Brisk walking has been associated with a lower risk of total and ischemic stroke [72]. In the Harvard Alumni study, the risk of stroke was lower at a weekly energy expenditure of 4.2-8.4 MJ/wk (1000-1999 kcal/wk) (RR = 0.76 (95% CI, 0.59 to 0.98)). With expenditures of 8.4-12.6 MJ/wk (2000-2999 kcal/wk) the RR dropped to 0.54 (0.38 to 0. 76) [73]. Thus, the recommended daily expenditure of Canada's physical activity guidelines is sufficient to reduce the risk for stroke. Further research is required to clearly determine the risk reductions at exercise volumes less than 4.2 MJ/wk (1000 kcal/wk).

In summary, the results of these studies (taken as a whole) indicate that occupation- and leisure time-related physical activity are inversely related to the risk for stroke. Both physically active men and women have a lower risk of stroke, and it appears that this benefit may be present for both ischemic and haemorrhagic stroke [74]. The relationship between physical activity and stroke appears to be consistent between men and women. Unfortunately, relatively limited data exists in non-Caucasian populations.

Recommendation #3

For a reduced risk of stroke, it is recommended that individuals should participate in 30 min or more of moderate to vigorous exercise on most days of the week. Brisk walking appears to be protective against the development of stroke. It remains to be determined whether lower volumes of physical activity lead to a reduced risk for stroke. [Level 3, Grade A]

Primary Prevention of Hypertension

A total of 6287 citations were identified during the electronic database search (Figure 6). Of these citations, 4054 were identified in MEDLINE, 1360 in EMBASE, 253 in Cochrane, and 620 in the CINAHL/SportDiscus/PsychInfo search. A total of 40 duplicates were found, leaving a total of 6247 unique citations. A total of 6167 articles were excluded after scanning, leaving a total of 80 articles for full review. An additional five articles were found through cross-referencing and the reviewers' personal files. From these articles 72 were excluded after full review for the following reasons: weak design (n = 4), did not contain three levels of physical activity or not possible to determine dose-response relationship (n = 19), reviews, summaries, meta-analyses (n = 8), not dealing with hypertension (n = 2), only reported on changes in blood pressure (n = 27), clinical population (n = 7), and other (n = 6). Therefore, a total of 12 articles were included in the systematic review of the literature regarding the relationship between physical activity and the primary prevention of hypertension. The majority of the literature examining the dose-response (for at least three levels of physical activity/fitness) involved prospective cohort analyses (83%).
https://static-content.springer.com/image/art%3A10.1186%2F1479-5868-7-39/MediaObjects/12966_2009_Article_345_Fig6_HTML.jpg
Figure 6

Results of the Literature Search for Hypertension.

As shown in Table 14, 12 investigations examined the dose-response (i.e., three or more levels) relationship between physical activity and the incidence of hypertension. This involved a total of 112,636 participants, averaging 10,240 subjects per study (range 1,243-41,837). There were a total of 11,441 reported cases of hypertension (ranging per study from 118-2,936). The total length of study follow-up averaged 8.6 yr (ranging from 0-16 yr). The articles were published over a 24 yr period ranging from 1983 to 2007.
Table 14

Studies examining the relationship between physical activity and hypertension.

Publication Country Study Design Quality Score

Objective

Population

Methods

Outcome

Comments and Conclusions

Rankinen et al 2007 [75]

To investigate the contributions of DNA sequence variation in candidate genes, PF and BMI, as well as their interactions to the incidence of hypertension.

• n = 629 cases; 605 controls

10 year follow up

PF showed the strongest association with HTN risk among all subjects as well as sex-specific models. Each 1- MET increment in PF was associated with 19% (12- 14%), 16% (9-22%), 32% (17- 45%) risk reduction in all subjects, men and women respectively.

PF is a significant predictor of the risk of hypertension.

USA

 

• Sex: Men and women

All subjects required to have 2 clinic visits at least 2 years apart.

  

Case control

 

• Age: Case: 43.3 (9.2) yr Control: 42.7 (8.9) yr

PF assessment: treadmill test (Blake protocol)

  

D & B score = 13

 

• Characteristics: Healthy with BP 134/86 mmHg or less at their first clinic visit. Cases: those who developed hypertension during the follow-up period. Controls were those who did not develop hypertension

Outcome measure: Incidence of hypertension during follow-up. Incident cases of hypertension were defined as physician diagnosed hypertension with medication or SBP ≥ 140 mmHg and/of DBP ≥ 90 mmHg t-tests and chi-square tests Logistic regression modelling

When divided into quartiles on the basis of sex specific MET cut-offs, the third and fourth quartiles had a 58% (41-71%) and 63% (47-75%) lower risk of hypertension compared to the 1 st quartile.

 

Pereira et al 1999 [76]

To examine PA and incident hypertension in men and women.

• n = 7,459

PA Assessment: Questionnaire for leisure, sport and work index, divided into quartiles

White Men

There is an inverse association between PA and incident hypertension in White middle aged men. White men in the highest quartiles of sport and leisure activity had statistically significant reductions in the odds of developing hypertension of 23 and 34% respectively, compared to men in the lower quartiles.

USA

 

• Sex: Men and women

Q1 = Lowest

Leisure Index Model 1

 

Prospective cohort

 

• Age: 45-65 yr

Q2

• Q1 = 1.00 (referent)

 

D & B score = 12

 

• Characteristics: No history of angina, MI, evidence of MI, angioplasty or other CV surgery or hypertension

Q3

• Q2 = 0.95 (0.70-1.28)

 
  

• Atherosclerosis Risk in Communities Study

Q4 = Highest

• Q3 = 0.83 (0.63-1.09)

 
   

Model 1 adjusted for: Age, education, baseline BP and study centre

• Q4 = 0.64 (0.46-0.89)

 
   

Model 2 adjusted for: Covariates in model 1 and smoking, alcohol consumption, parental history of hypertension, energy, sodium, potassium and caffeine intake, BMI, waist to hip ratio, menopausal status and hormone use

Trend p = 0.01

 
   

Outcome Measure: Incidence of hypertension as defined as a SBP 140 mmHg and/or a DBP 90 mmHg or use of antihypertensive medications.

Leisure Index Model 2

 
   

Unconditional logistic regression Orthogonal polynomial coefficients

• Q1 = 1.00 (referent)

 
    

• Q2 = 0.99 (0.72-1.35)

 
    

• Q3 = 0.86 (0.65-1.13)

 
    

• Q4 = 0.66 (0.47-0.94)

 
    

Trend p = 0.01

 
    

Women

 
    

Sport Index Model 1

 
    

• Q1 = 1.00 (referent)

 
    

• Q2 = 1.26 (0.78-2.05)

 
    

• Q3 = 1.06 (0.61-1.84)

 
    

• Q4 = 1.92 (1.12-3.29)

 
    

Trend p = 0.04

 
    

Men

 
    

Sport Index Model 1

 
    

• Q1 = 1.00 (referent)

 
    

• Q2 = 1.23 (0.91-1.66)

 
    

• Q3 = 0.92 (0.70-1.22)

 
    

• Q4 = 0.74 (0.54-1.02)

 
    

Trend p = 0.02

 
    

Sport Index Model 2

 
    

• Q1 = 1.00 (referent)

 
    

• Q2 = 1.26 (0.93-1.71)

 
    

• Q3 = 0.95 (0.71-1.26)

 
    

• Q4 = 0.77 (0.55-1.08)

 
    

Trend p = 0.05

 

Haapanen et al 1997 [77]

To assess the association between PA and hypertension.

• n = 732 men; 796 women

10 year follow up (1980 baseline)

Age adjusted incidence rates ofhypertension Total energy expenditure High as referent:

Increased EE during LTPA and increased intensity of these activities were associated with reduced risk for incident hypertension (age adjusted) in men but not women.

Finland

 

• Sex: Men and women

PA assessement: Questionnaire for EE (kcal/wk), divided into tertiles

  

Prospective cohort

 

• Age: 35-65 years

Male

Male:

 

D & B score = 11

 

• Characteristics: Free of hypertension at baseline. Excluded those unable to participate in regular PA due to poor health

   T1 = Low = 0-1100

• T1 = 1.00 (referent)

 
   

   T2 = Medium = 1101-1900

• T2 = 1.66

 
   

   T3 = High >1900

• T3 = 1.73

 
    

Trend p = 0.021

 
   

Female

Female:

 
   

   T1 = Low = 0-900

• T1 = 1.00 (referent)

 
   

   T2 = Medium = 901-1500

• T2 = 0.94

 
   

   T3 = High = >1500

• T3 = 1.16

 
   

Outcome measure: Incidence of hypertension through self reported diagnosis and death certificates

Trend p = 0.648

 
   

Cox proportional HR

  

Paffenbarger et al 1983 [78]

To examine the relationship of student and alumnus PA patterns and other characteristics with incident hypertension.

• n = 14,998

PA Assessment: Questionnaire for PA based on number of stairs ascended, blocks walked and hours per week of light and vigorous sports play, yard work etc.

There was no significantly reduced risk for hypertension in men who climbed 50 plus stairs per day (compared to < 50 stairs); who walked 5 plus blocks per day (compared to < 5 blocks); or who played light sports (compared to those who did not).

Contemporary vigorous exercise was inversely related to hypertension risk.

USA

 

• Sex: Men

   

Prospective cohort

 

• Age: 35-74 yr

Outcome measure: Diagnosis of hypertension by physicians using criteria of SBP > 160 mmHg and/or DBP > 95 mmHg

The 59% of men who did engage in vigorous sports were at 35% greater risk of hypertension than the 41% who did not.

 
    

RR = 1.35

 
    

Trend p = <0.001

 

D & B score = 12

 

• Characteristics: free of hypertension Harvard Alumni Study

Multivariate estimates

Alumni on the low side of the physical activity index (< 2000 kcal/wk) had a 30% increased risk of hypertension then those ≥ 2000 kcal/wk.

 
    

RR = 1.30

 
    

Trend p = 0.004

 

Paffenbarger et al 1997 [79]

To investigate the quantity and intensity of energy expenditure required to delay hypertension and prevent premature death.

• n = 6,390

PA Assessment: Questionnaire for weekly sports play, divided into tertiles

RR (95% CI)

Lack of vigorous sports play independently increased the risk of developing hypertension.

USA

 

• Sex: Men

T1 = None

• T1 = 1.00 (referent)

 

Prospective cohort

 

• Age: 45-84 yr

T2 = Light Only (< 4.5 METs)

• T2 = 1.04 (0.77-1.40)

 

D & B score = 12

 

• Characteristics: Free of hypertension, CHD, diabetes, COPD and potentially malignant cancer in 1977

T3 = Moderately vigorous (≥ 4.5 METs)

• T3 = 0.77 (0.62-0.96)

 
  

• Harvard Alumni Study

Outcome measure: Incident hypertension

Trend p = 0.004

 

Hu et al 2004 [81]

To discover whether regular PA can reduce the risk of hypertension in normal weight and overweight men and women.

• n = 8,302 men; 9,139 women

11 year follow up

Multivariate adjusted HR (95% CI), men

Regular PA can reduce the risk of hypertension. The protective effect of PA was observed in both sexes regardless of level of obesity.

Finland

 

• Sex: Men and women

PA assessement: Questionnaire for OPA, LTPA and commuting PA, divided into tertiles

• T1 = 1.00 (referent)

 

Prospective cohort

 

Age: 25-64 yr

T1 = Low

• T2 = 0.63

 

D & B score = 13

 

Characteristics: Healthy and free of hypertension at baseline

T2 = Medium

• T3 = 0.59

 
   

T3 = High

Trend p = < 0.001

 
   

Outcome Measure: Incidence of drug treated hypertension

Multivariate adjusted HR (95% CI), women

 
   

Cox proportional HR

• T1 = 1.00

 
    

• T2 = 0.82

 
    

• T3 = 0.71

 
    

Trend p = 0.005

 

Gu et al 2007 [82]

To determine the 8-year incidence of HTN and its risk factors among Chinese adults.

• n = 10,525

Baseline Examination in 1991 with 8 year follow up

RR (95% CI), men

Increasing PA has the potential to reduce incidence of hypertension.

China

 

• Sex: Men and women

PA assessment: Questionnaire administered by trained staff, divided into groups

• G1 = 1.00 (referent)

 

Prospective cohort

 

Age: ≥ 40 yr

G1 = Low

• G2 = 1.12 (0.86-1.46)

 

D & B score = 13

 

Characteristics: Healthy and free from hypertension at baseline.

G2 = Medium

• G3 = 1.27 (1.10-1.47)

 
   

G3 = High

RR (95% CI), women

 
   

Outcome measure: HTN as defined at SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg or current use of antihypertensive medication

• G1 = 1.00 (referent)

 
   

t-tests, chi squared tests, Cochran-Armitage modeling, Modified Poisson approach

• G2 = 1.14 (0.98-1.34)

 
    

• G3 = 1.22 (1.02-1.45)

 

Hayashi et al 1999 [83]

To investigate the association of the duration of the walk to work and LTPA with the risk for hypertension.

• n = 6,017

PA assessment: Questionnaire on health related behaviours and exercise Walk time to work

RR (95% CI) Frequency walk time to work (minutes

The duration of walk to work was associated with a decreased risk of hypertension even after adjustment.

Japan

 

• Sex: Men

T1 = 0-10 min

• T1 = 1.00 (referent)

Regular PA (at least once weekly) was inversely related to the risk of incident hypertension

Prospective cohort

 

• Age: 35-60 yr

T2 = 11-20 min

• T2 = 0.65 (0.47-0.90)

 

D & B score = 12

 

• Characteristics: Free from HTN at baseline. All employees at gas company in Osaka Japan. All had sedentary jobs.

T3 = ≥ 21 min

• T3 = 0.72 (0.59-0.88)

 
   

Outcome measure: Diagnosed with hypertension (as defined by a SBP ≥ 160 mmHg, a DBP ≥ 95 mmHg, or use of antihypertensive medication)

Trend p = < 0.001

 
   

Cox proportional HR

  

Nakanishi et al 2005 [84]

To examine the relationship of overall PA to the risk of developing hypertension in normotensive Japanese male office workers over a 7 year observation period.

• n = 2,548

7 year follow up

Multivariate adjusted RR (95% CI) by PA level only

The rate of rise in both SBP and DBP in each follow-up year decreased with higher EE and that the risk of developing hypertension decreased in a dose dependent manner with higher daily life activity level.

Japan

 

• Sex: Men

 

Q1 = 1.00 (referent)

Analysis stratified by the presence of or absence of a risk factor showed the negative association of daily life activity with the risk of developing hypertension for men at both low and high risk. This tendency was also observed among men in all 3 categories of normotension.

Prospective cohort

 

• Age: 35-59 yr

PA assessment: 1-day activity record and reported the type and frequency on a weekly basis of LTPA, divided into quartiles (kcal/kg/d)

Q2 = 0.84 (0.72-0.98)

 

D & B score = 12

 

• Characteristics Healthy at baseline. No hypertension or CHD. All office workers for a Japanese company

• Q1 = <33.3

• Q3 = 0.75 (0.63-0.88)

 
   

• Q2 = 33.3-36.9

• Q4 = 0.54 (0.45-0.64)

 
   

• Q3 = 37.0-40.3

Trend p = < 0.001

 
   

• Q4 = 40.4

Multivariate adjusted RR (95% CI) by PA level, low normal BP

 
   

3 categories of normotensive BP Low Normal: SBP < 120, DBP < 80 Normal: SBP 120-130, DBP 80- 85 High Normal: SBP 130-139 DBP 85-89

• Q1 = 1.00 (referent)

 
   

3 categories of normotensive BP Low Normal: SBP < 120, DBP < 80 Normal: SBP 120-130, DBP 80- 85 High Normal: SBP 130-139 DBP 85-89

• Q2 = 0.70 (0.47-1.05)

 
   

Cox proportional hazard model

• Q3 = 0.55 (0.37-0.83)

 
    

• Q4 = 0.43 (0.28-0.65)

 
    

Trend p = <0.001

 
    

Multivariate adjusted RR (95% CI) by PA level, normal

 
    

BP

 
    

• Q1 = 1.00 (referent)

 
    

• Q2 = 0.89 (0.68-1.16)

 
    

• Q3 = 0.69 (0.52-0.91)

 
    

• Q4 = 0.50 (0.37-0.68)

 
    

Trend p = <0.001

 
    

Multivariate adjusted RR (95% CI) by PA level, high normal BP

 
    

• Q1 = 1.00 (referent)

 
    

• Q2 = 0.86 (0.69-1.07)

 
    

• Q3 = 0.88 (0.69-1.11)

 
    

• Q4 = 0.60 (0.46-0.78)

 
    

Trend p = 0.001

 

Foy et al 2006 [85]

To examine whether insulin resistance is associated with the effect of vigorous or moderate PA on baseline BP.

• n = 1,599

Baseline examination in 1992-1993

Unadjusted OR (95% CI)

Participants who meet or exceed current caloric expenditure recommendations for VPA demonstrate significantly less hypertension than do sedentary or underactive individuals.

USA

 

• Sex: Men and women

PA assessment: VPA over the past year was determined via a 1-year recall of physical activity (kcal/d), divided into 3 groups

• T1 = 1.00 (referent)

 

Cross sectional

 

• Age: 40-69 yr

• T1 = O

• T2 = 0.69 (0.53-0.88)

 

D & B score = 12

 

• Characteristics: Community dwelling adults

• T2 = 1-149 kcal/day

• T3 = 0.57 (0.45-0.74)

 
  

• Insulin Resistance Atherosclerosis Study

• T3 = >150 kcal/day

• Trend p = < 0.001

 
    

Adjusted OR (95% CI)

 
    

• T1 = 1.00 (referent)

 
    

• T2 = 0.82 (0.62-1.09)

 
    

• T3 = 0.73 (0.55-0.98)

 
    

Trend p = 0.004

 

Folsom et al 1990 [270]

To examine the relationship between fat distribution and the 2-yr incidence of hypertension and stroke.

• n = 41,837

Baseline mailed survey in 1986: Pa assessment: Questionnaire for LTPA

• 978 cases

High PA reduced the risk of hypertension only before adjusting for other factors.

USA

 

• Sex: Women

T1 = Low

Age Adjusted RR (95% CI)

 

Prospective cohort

 

• Age: 55-69 years (yr)

T2 = Medium

• T1 = 1.00 (referent)

 

D & B score = 12

 

• Characteristics: All free of HTN at baseline

T3 = High

• T2 = 0.9 (0.7-1.1)

 
   

Mantel-Haenszel method

• T3 = 0.7 (0.6-0.9)

 
   

Multiple logistic regression

  

Levenstein et al 2001 [271]

To examine the effects of a variety of psychosocial factors on the development of HTN in men and women in the general population.

• n = 1,031 men, 1,326 women

Questionnaires in 1965 and 1974, cohort followed until 1994

LTPA predictor of hypertension OR (95% CI)

Risk of HTN was reduced with increases in LTPA in women.

USA

 

• Sex: Men and women

PA assessment: LTPA rated on a scale of 0-16 points and analysed as a continuous variable

• All Subjects: 0.94 (0.91-0.97)

 

Prospective cohort

 

• Characteristics: Free of hypertension at baseline

Outcome measure: Incidence of hypertension (defined as those who are taking antihypertensive medications)

• Women: 0.90 (0.87-0.94)

 

D & B score = 13

 

• Alameda cohort study

Logistic regression analysis

• Men: 0.98 (0.94-1.02)

 

D & B score, Downs and Black quality score; YR, years; PF, physical fitness; BMI, body mass index; MET, metabolic equivalent; PA, physical activity; MI, myocardial infarction; G, groups; Q, quartile or quintile; 95% CI, confidence interval; SBP, systolic blood pressure; DBP, diastolic blood pressure; EE, energy expenditure; kcal/wk, kilocalories per week; T, tertile; RR, risk ratio; HR, hazard ratio; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; OPA, occupational physical activity; LTPA, leisure-time physical activity; BP, blood pressure; kcal/day, kilocalories per day.

All studies reviewed demonstrated positive effects of physical activity on the risk for hypertension. Of these studies all (7; 58%) revealed an inverse and graded relationship between hypertension and at least one measure of physical activity or fitness. Across all studies, when comparing the most active/fit group versus the least active/fit group we found an average RR of 0.68 (median = 0.70, range 0.37 to 0.90). Therefore, we observed that physical activity/fitness was associated with an average risk reduction of 32% for hypertension. It should be noted that the study [75] demonstrating the largest risk reduction (63%) evaluated cardiorespiratory fitness directly during a maximal treadmill test. This supports research (as discussed previously) which indicates that physical fitness is a better predictor of chronic disease than physical activity [6, 18, 19, 32, 33]. Taken as a whole, the level of evidence can be classified as Level 3A. The quality of studies was generally good with a mean Downs and Black score of 11 (median = 11, range = 10-12).

Five studies showed variable results (i.e., no clearly defined dose-response) while generally supporting the inverse relationship between physical activity/fitness and hypertension [7680]. The variability in the response appears to be the result of different activity/fitness classifications and/or differing subject populations. For instance, some studies revealed that the dose-response relationships differed between genders and/or ethnicities [76, 77]. Pereira et al. [76] revealed a 30% reduction in the risk for hypertension in the most active white men. There were graded dose-response relationships between indices of both leisure and sport activities in the white men.

However, there was a lack of association between physical activity and hypertension in white women and African American men and women. Similarly, Haapenen et al. [77] revealed a stronger association in men than in women. However, it should be noted clearly that other studies included in this systematic review evaluated women demonstrating a graded response [81]. Moreover, several studies were conducted with non-Caucasian populations and demonstrated a dose-dependent benefit [8285]. In fact, data was obtained from varied regions of the world including USA (7), Japan (2), China (1), and Finland (1). Therefore, there is evidence to suggest that the protective effects of physical activity with respect to hypertension are transferable to women and non-Caucasian populations. However, further research is clearly warranted that examines the relationship between physical activity and hypertension in persons of different ethnicities. Moreover, further research is needed to determine the effects of impact of socio-economic status on the observed relationships.

Some studies have indicated that vigorous activity is required to reduce the risk for hypertension. For instance, Paffenbarger [78] revealed that Harvard Alumni who did not engage in vigorous sports play were at a 35% higher risk for developing hypertension. However, there was no difference in the risk for hypertension in men who climbed >50 stairs per day, walked more than 5 city blocks daily, or engaged in light sports only. Similarly, the Paffenbarger and Lee [79] study revealed that moderately vigorous sports play was associated with a lower risk for hypertension, but physical activity (kcal/wk), walking distance (km/wk) and the amount of stairs climbed (floors/wk) were not significant predictors of the risk for hypertension. Collectively, this research group concluded that these findings highlighted the importance of the intensity of effort.

However, it should be noted that many of the studies in our systematic review observed the protective effect with moderate i