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Physical Activity and Coronary Heart Disease in

Middie-Aged and Elderiy Men: The Honolulu Heart Program


R I C H A R D P. D O N A H U E , P H D , R O B E R T D . A B B O T T , P H D , D W A Y N E M . R E E D , M D ,
AND K A T S U H I K O Y A N O ,

PHD,

MD

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.

ment of cardiovascular disease.** 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.'*
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 Framingham' and Puerto Rico^
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.'"
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 Framingham'' and Puerto Rico^ 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

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

AJPH June 1988, Vol. 78, No. 6

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/m^), 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."
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 1Mean 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
(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]

Number of subiects without pre- or coexisting angina pectoris, coronary insufticiency,


or myocardial infarction at study entry.
^Standard deviation

684

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


Activity
Level of
Physical Activity
Aged 45 to 64 Years
Inactive
Moderately active
Active
Total
Aged 65 and Older
Inactive
Moderately active
Active
Total

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

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% Cl, 0.19, 0.99).
TABLE 3Twelve-year Incidence of Definite Coronary Heart Disease by
Level of Physical Activity
Level of
Physical Activity
Aged 45 to 64 Years
Inactive
Moderately active
Active
Total
Aged 65 and Older
Inactive
Moderately active
Active
Total

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

Compared with active men: p = 0.004


IJCompared with active men; p = 0.038

AJPH June 1988, Vol. 78, No. 6

PHYSICAL ACTIVITY IN MIDDLE-AGED AND ELDERLY MEN


TABLE 4Estimated Reiative Risic of Definite Coronary Heart Disease for
Active versus inactive Men after Adjusting for Several Variables

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

Aged 65 and Over

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

95% confidence interval in brackets

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

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 of attention 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.'* As a result, approaches to prevent or delay disabling
coronary events are clearly desirable." If findings from the
Honolulu study are replicated elsewhere, a clinical trial of
increased physical activity in the elderly may be warranted.
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