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Abstraet: The relationship of physical activity to the development of definite coronary heart disease was examined separately In
middle-aged (45-64 years) and elderly men (65-69 years) participating in the Honolulu Heart Program. After 12 years of follow-up,
results indicate that increased levels of physical activity reported at
study entry were inversely related to the risk of definite coronary
heart disease in both age groups. In particular, among those aged 45
to 64 years, the rate of definite coronary heart disease in men who led
active life styles was 30 per cent lower than the rate experienced by
those who were less active (relative risk, 0.69; 95% confidence
interval, 0.53, 0.88). In those older than 64 years, the rate of definite
coronary heart disease in active men was less than half the rate
experienced by those who led more sedentary life styles (relative
risk, 0.43; 95% Cl, 0.19, 0.99). These results continued to hold up
when controlling for several cardiovascular risk factors and potentially confounding variables, supporting earlier observations that
physical activity is beneficial in middle-age, and further suggesting
that benefits may extend to the elderly male population as well. (Am
J Public Health 1988; 78:683-685.)
Introduction
Cardiovascular disease is the most common cause of
death among those older than 65 years.' Currently, II per
cent of the noninstitutionalized civilian population in the
United States is 65 years or older. In the next 50 years, this
percentage is expected to doubled.^
The shift in the demographic distribution of the population indicates a growing demand on health care resources by
the elderly. Thus, identification of health practices which
may prevent or delay coronary heart disease in the elderly is
clearly important. In addition, positive health behavior encouraged during youth and middle-age which can reduce the
risk of disabling disease, can improve the capacity to continue such behavior into the older years, where additional
benefits in risk reduction may be realized.
Maintaining physically active life styles may be one such
health practice which can reduce the risk of coronary heart
disease among all ages. In middle-aged men, however, the
beneficial effects of physical activity on reducing the risk of
coronary heart disease have not been consistently demonstrated.'"^ Furthermore, the paucity of data on older individuals makes it difficult to identify any salutary effects of
physical activity in the elderly population as well.
After 12 years of follow-up, the Honolulu Heart Program
has accrued sufficient data to enable further examination of
the association between physical activity and definite coronary heart disease in both middle aged (45-64 years) and
elderly (65-^9 years) men. This report presentsfindingsbased
on the long-term follow-up of the cohort of subjects originally
enrolled in the Honolulu Heart Program.
Methods
From 1965 to 1968, the Honolulu Heart Program began
following 8,006 men of Japanese ancestry for the developAddress reprint requests to Richard P. Donahue, PhD, Department of
Medicine, Division of General Medicine and Primary Care, University of
Massachusetts Medical Center, 55 Lake Avenue, North, Worcester, MA
01655. Dr. Abbott is with the Statistical Resource Section, National Heart,
Lung, and Blood Institute, Bethesda, MD; Dr. Reed is with the Honolulu
Epidemiology Research Section, NHLBI, Honolulu, HI 96817; Dr. Yano is
with the Honolulu Heart Program, Kuakini Medical Center, Honolulu. This
paper, submitted to the Journal August 10, 1987, was revised and accepted for
publication November 18, 1987.
1988 American Journal of Public Health 0090-0036/88$ 1.50
683
DONAHUE, ET AL.
Basal
Sedentary
Slight
Moderate
Heavy
Oxygen
Consumption Weight Aged 45 to 64 Years Aged 65 and Older
(L/min)
Factor
(7221 )
(423)
0.25
0.28
0.41
0.60
1.25
1.0
1.1
1.5
2.4
5.0
7.3 [1.1)11
7.3 [3.1]
6.1 [2.7]
3.1 [2.6]
0.2 [0.8]
7.8 [1.4]
6.8 [2.9J
6.1 [2.7]
3.2 [2.2]
0.1 [0.3]
684
Number at Risk
Mean
Standard
Deviation
2362
2440
2419
7221
28.5
31.9
38.0
32.9
1.1
1.2
3.8
4.6
24.1
30.2
34.5
24.1
to
to
to
to
30.1
34.4
65.5
65.5
142
28.9
32.2
36.1
32.4
1.2
0.9
2.1
3.3
26.3
30.8
33.8
26.3
to
to
to
to
30.7
33.7
47.8
47.8
140
141
423
Range
Number at Risk
Number of Events
2362
2440
2419
7221
149
150
107
142
140
141
423
Unadjusted
Rate/1000
406
63.1
61.5
44.2
56.2
18
12
8
38
126.811
85.7
56.7
89.8
Adjusted for:
Age
Systolic blood
pressure
Body mass index
Total cholesterol
Cigarette use
Alcohol intake
Left ventricular
hypertrophy
Resting ventricular
rate
Age, alcohol intake.
and cigarette use
Aged 45 to 64 Years
Estimated relative
risk
Estimated relative
risk
0.69
[0.54,0.88]
0.42
[0.18,0.96j
0.73
[0.57,0.94]
0.74
[0.57,0.95]
0.72
[0.56,0.92]
0.68
[0.53,0.87]
0.71
[0.55,0.91]
0.42
[0.18,0.96]
0.43
[0.19,0.99]
0.42
[0.18,0.97]
0.41
[0.18,0.94]
0.43
[0.19,0.99]
0.72
[0.56,0.92]
0.39
[0.17,0.89]
0.70
[0.55,0.90]
0.41
[0.18,0.94]
0.69
[0.53,0.88]
0.43
[0.19,0.991
Discussion
Our findings indicate that physical activity is inversely
related to the risk of coronary heart disease in middle-aged
men, consistent with a number of other investigations.'**''^'' This is the first report from the Honolulu
Heart Program which also demonstrates a relationship between physical activity and hard or definite coronary events,
i,e., after excluding angina pectoris and coronary insufficiency. In addition, this report focuses further on the benefits
of active life styles in the elderly, supporting evidence that
increased activity is associated with reduced coronary risk in
older individuals as well."'''*
Unfortunately, observational studies are not always the
best way of documenting the link between physical activity
and the risk of coronary heart disease, primarily due to
difficulties in measuring highly variable behavioral patterns
based on self-report and individual recall. The self-selection
of men into levels of activity is also a source of potential bias,
which may be greatest at the low end of the physical activity
spectrum due to the involuntary nature of disability, physical
impairment, and occult disease,'^ Selection bias also exists
among older members of the Honolulu cohort, as the force of
morbidity and mortality has removed the less healthy, leaving
a group of "fit" survivors. Since physical activity was
reported only at the baseline examination, effects of changing
activity over the course of follow-up on heart disease cannot
be addressed.
Changes in activity levels at retirement may also help
determine if the coronary effects of work and leisure time
activity are different. One can only speculate from the
Honolulu sample. Among the men younger than 65, less than
3 per cent were retired, suggesting that the benefits of some
activity could be work-related. In contrast, 60 per cent of the
AJPH June 1988, Vol. 78, No. 6