Physical Activity and Coronary Heart Disease in Middle-Aged and Elderly Men: The Honolulu Heart Program

RICHARD P. DONAHUE, PHD, ROBERT D. ABBOTT, PHD, DWAYNE M. REED, MD, PHD, AND KATSUHIKO YANO, MD
Abstract: 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% CI, 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, 11 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.2 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.7 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 (65-69 years) men. This report presents findings based 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

ment of cardiovascular disease.8 In this report, up to 12 years of follow-up data for each subject are utilized to examine the relation between physical activity and definite coronary heart disease. At study entry, subjects (45-69 years of age) were given routine baseline examinations to detect the presence of cardiovascular disease. For this report, follow-up is limited to 7,644 individuals who were enrolled in the Honolulu Heart Program without pre- or coexisting angina pectoris, coronary insufficiency, or myocardial infarction. Follow-up for cardiovascular events in the 12 years after study enrollment was based on comprehensive surveillance of hospital discharges, death certificates, autopsy records, and repeat examinations given at two and six years into follow-up. Physical activity was assessed only at the baseline examination. For this report, subjects were followed for the first occurrence of definite coronary heart disease, defined to include nonfatal myocardial infarction and death from coronary heart disease. Further details on the definition of these events are given elsewhere.8 In the Honolulu Heart Program, a history of usual 24-hour physical activity was elicited from each subject at the time of study enrollment. Questions were asked concerning the average hours per day spent in basal (sleeping or lying down), sedentary (sitting or standing), slight (e.g., casual walking), moderate (e.g., gardening or carpentry), and heavy (e.g., lifting or shoveling) levels of activity based on similar questionnaires used in the Framingham9 and Puerto Rico5 heart studies. A weighting factor, based on the approximate oxygen consumption needed for each level of effort, was multiplied by the number of hours engaged in that activity.'0 The resulting products for all activities were then summed to yield an index of physical activity. The final summary measure of physical activity resembles the physical activity index used in the Framingham9 and Puerto Rico5 heart studies. Subjects were further classified into tertiles of physical activity for those aged 45 to 64, and separately for those 65 and older. For those aged 45 to 64, inactive men consisted of those whose index of physical activity was in the first tertile (less than 30.2). Moderately active men consisted of individuals whose index of physical activity fell in the second tertile (30.2 to 34.4). Active men had physical activity indices in the third tertile (exceeding 34.4). A similar grouping of those 65 and older was also made except that the first tertile consisted

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683

DONAHUE, ET AL.

of physical activity indices less than 30.8, the second tertile consisted of indices ranging from 30.8 to 33.7, and the third tertile consisted of indices exceeding 33.7. To examine the independent effect of physical activity on disease, proportional hazards models" were used to follow subjects for the first development of definite coronary heart disease in 12 years. Estimates of relative risk were based on the corresponding regression coefficient comparing active to inactive men. Comparisons were made separately for those younger than 65, and for those 65 and older. In order to assess the extent to which levels of physical activity may affect the risk of coronary heart disease through other biological mechanisms, risk factor adjustments were made for factors thought to mediate the effects of an active life style. The factors included total cholesterol, systolic blood pressure, body mass index (kg/mi2), resting ventricular rate, and left ventricular hypertrophy by ECG. Additional analyses controlled for the confounding effects of cigarette smoking, alcohol intake, and any residual effect of age. All concomitant risk factors and confounders were measured at the beginning of follow-up when physical activity was assessed. Techniques used to measure the concomitant information are described elsewhere.8 Fit of the proportional hazards model was evaluated by permitting the proportionality assumption to vary with time and with risk factor level. Tests of significance were twosided. Results Table 1 shows the mean number of hours reported in each of five levels of activity for each age group which comprise the index of physical activity. Men in both age groups spent the majority of time in basal or sedentary activities. Fewer than four hours per day were reportedly spent in moderate or heavy activities. Table 2 provides the mean and range of the physical activity index for middle-aged and older men by level of physical activity. Among men aged 45 to 64 years, the average physical activity index was 32.9 (standard deviation, 4.6), and for those older, the average was 32.4 (standard deviation, 3.3). Although the young men appeared to be only slightly more active than their older counterparts, the range in physical activity indices in the highest level of activity indicates there were younger men who maintained extremely active life styles relative to those who were older. In Table 3, the 12-year unadjusted incidence rate of definite coronary heart disease is given by level of physical activity for both age groups of men. Among those aged 45 to
TABLE 1-Mean Number of Hours Spent in Each Component of Physical Activity by Age Group
Mean Number of Hours Activity Level Basal Sedentary Slight Moderate Heavy Oxygen Consumption Weight Aged 45 to 64 Years Aged 65 and Older Factor (7221) (L/min) (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] 7.3 [3.1] 6.1 [2.7] 3.1 [2.6] 0.2 [0.8]

TABLE 2-Mean and Range of Physical Activity Index by Level of Physical

Activity

Level of

Physical Activity

Number at Risk 2362 2440 2419 7221

142 140 141 423

Mean

Standard Deviation 1.1 1.2 3.8 4.6

1.2 0.9 2.1 3.3

Range
24.1 to 30.1 30.2 to 34.4 34.5 to 65.5 24.1 to 65.5
26.3 to 30.7 30.8 to 33.7 33.8 to 47.8 26.3 to 47.8

Aged 45 to 64 Years
Inactive

Moderately active
Active Total Aged 65 and Older Inactive Moderately active Active Total

28.5 31.9 38.0 32.9

28.9 32.2 36.1 32.4

64, the rates of definite coronary heart disease were similar between men who were inactive and moderately active. The rate of definite coronary heart disease among the most active group, however, was nearly 30 per cent lower than in those who were either inactive or moderately active. When considered as a continuous variable, physical activity index was inversely related to definite heart disease. A more pronounced trend was observed in the elderly men. Here, the rate of definite coronary heart disease decreased from 126.8/1000 in inactive men to less than half this rate in those who were most active (56.7/1000). As with younger men, physical activity index as a continuous variable was inversely related to definite coronary heart disease. To help describe the extent to which the effect of physical activity on definite coronary heart disease can be explained by concomitant markers of health status, Table 4 provides estimates of relative risk for active versus inactive men after adjusting for several risk factors and potentially confounding variables. Among men aged 45 to 64, the 30 per cent reduction in coronary risk in active versus inactive men was virtually unchanged after controlling for the concomitant information. Among the elderly men, the nearly 60 per cent reduction in risk among active men as compared to those who were sedentary was also unaffected after adjusting for the other variables. The relative risk estimates, simultaneously adjusted for age, alcohol intake, and cigarette use, also had little effect on explaining the relationship between physical activity and disease. Once again, active men in either age group displayed a significant reduction in risk as compared to inactive men. For younger men, the corresponding relative risk of disease was 0.69 (95% CI, 0.53, 0.88), and for older men, the relative risk was 0.43 (95% CI, 0.19, 0.99).
TABLE 3-Twelve-year Incidence of Definite Coronary Heart Disease by Level of Physical Activity
Level of Physical Activity

Number at Risk
2362 2440 2419 7221
142 140 141 423

Number of Events
149 150 107 406
18 12 8 38

Unadjusted Rate/1 000

63.1 61.5
44.2 56.2

7.8 [1.4] 6.8 [2.9] 6.1 [2.7] 3.2 [2.2] 0.1 [0.3]

Inactive Moderately active Active Total Aged 65 and Older Inactive Moderately active Active Total

Aged 45 to 64 Years

126.81 85.7 56.7 89.8

Number of subjects without pre- or coexisting angina pectoris, coronary insufficiency, or myocardial infarction at study entry. Standard deviation

Compared with active men: p = 0.004 fCompared with active men: p = 0.038

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PHYSICAL ACTIVITY IN MIDDLE-AGED AND ELDERLY MEN

TABLE 4-Estimated Relative Risk of Definite Coronay Heart Diseasefor Active versus Inactive Men after Adjusting for Several Variables
Aged 45 to 64 Years Aged 65 and Over

Adjusted for:
Age

Estimated relative risk

0.69

Estimated relative risk

0.42

[0.54,0.88J

Systolic blood pressure

Body mass index
Total cholesterol

[0.18,0.961
0.42

0.73 [0.57,0.94] 0.74

[0.18,0.96]
0.43
0.42

[0.57,0.951
0.72

[0.19,0.99]

Cigarette use
Alcohol intake Left ventricular hypertrophy

[0.56,0.92]
0.68

[0.18,0.97]
0.41

[0.53,0.87]
0.71

[0.18,0.94]
0.43

[0.55,0.911
0.72

[0.19,0.991
0.39

Resting ventricular
rate

[0.56,0.92]
0.70

[0.17,0.89]
0.41

Age, alcohol intake, and cigarette use

[0.55,0.901
0.69

[0.18,0.94]
0.43

[0.53,0.88]
95% confidence interval in brackets

[0.19,0.99]

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 .3 68,9"12, 3 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.'3",4 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.'5 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

elderly were retired. Among this group, the age-adjusted relative risk of definite coronary heart disease for active versus inactive men was 0.29 (95% CI, 0.09, 0.93), consistent with the hypothesis that leisure time activity is also inversely related to disease. The magnitude of the relative risk estimates in Table 4 are at least provocative and suggest that apparent reductions in risk cannot be totally explained through differences in other risk factors or the confounding influence of alcohol intake or the use of cigarettes. Thus, the mechanism by which increased physical activity protects against coronary heart disease needs further study. Whether its benefits are derived from alterations in high density lipoprotein cholesterol, changes in clotting factors, or to increased myocardial contractibility deserves close examination. The focus ofattention on the independent predictive ability of physical activity may in fact be misplaced. Since less active life styles are more often accompanied by an atherogenic risk profile, increases in physical activity may be a sensible way of altering coronary heart disease susceptibility. In summary, the identification of factors which predict coronary heart disease among the elderly may be more important than examining factors which are related to the underlying atherosclerotic process, especially since differences in atherosclerosis on autopsy between elderly individuals with and without coronary heart disease may be minimal.'6 As a result, approaches to prevent or delay disabling coronary events are clearly desirable.'7 If findings from the Honolulu study are replicated elsewhere, a clinical trial of increased physical activity in the elderly may be warranted.
1. US Public Health Service: Healthy People: The Surgeon General's report on health promotion and disease prevention. DHEW Pub. No. (PHS) 79-55071. Washington, DC: Govt Printing Office, 1979. 2. US Bureau of the Census: The projections of the population of the United States by age, race and sex, 1983-2030. Current Population Reports, Series P-25, NO. 952, May 1984. 3. Paffenbarger RS Jr, Wing AL, Hyde RT: Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1970; 100:161-175. 4. Morris JN, Kagan A, Pattison DC, et al: Incidence and prediction of ischaemic heart disease in London busmen. Lancet 1966; 2:553-559. 5. Garcia-Palmieri MR, Costas R, Cruz-Vidal M, et al: Increased physical activity: a protective factor against heart attack in Puerto Rico. Am J

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