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Received April 7, 1998; final revision received July 13, 1998; accepted July 13, 1998.
From the Department of Epidemiology, Harvard School of Public Health, Boston, Mass (I-M.L., R.S.P); Division of Preventive Medicine, Department
of Medicine, Brigham and Womens Hospital and Harvard Medical School, Boston, Mass (I-M.L.); and Division of Epidemiology, Stanford University
School of Medicine, Stanford, Calif (R.S.P.).
This is report No. LXI in a series on chronic disease in former college students.
Correspondence to I-Min Lee, MBBS, ScD, Brigham and Womens Hospital, 900 Commonwealth Ave E, Boston, MA 02215. E-mail
i-min.lee@channing.harvard.edu
Reprint requests to I-Min Lee, MBBS, ScD, Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115.
1998 American Heart Association, Inc.
2049
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by guest on November 4, 2014
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same cut points as before in analyses. For light energy expenditure, men
distributed themselves thus: none, 63.9%; 1 to ,250, 10.3%; 250 to
,600, 8.2%; 600 to ,1400, 8.7%; and $1400 kcal/wk, 8.9%. For
energy expended on activities of $4.5 METs, the distribution was
36.4%, 15.8%, 12.7%, 16.7%, and 18.4%, respectively.
On the 1977 questionnaire, we also asked about cigarette smoking
(categorized in analyses as nonsmoker, smoker of #20, or .20
cigarettes per day), alcohol consumption (,50, 50 to 199, or $200
g/wk), ages of parental death (neither, 1, or both parents died before
age 65 years), weight and height (combined as body mass index;
,22.5, 22.5 to ,23.5, 23.5 to ,24.5, 24.5 to ,26.0, or $26.0
kg/m2), physician-diagnosed hypertension (no, yes, or unknown),
and diabetes mellitus (no, yes, or unknown).
Statistical Analyses
We used proportional hazards regression to analyze time to first
stroke occurrence (ascertained from the 1988 questionnaire or death
certificate) or censoring (1988 questionnaire return or death, whichever occurred later).41 There was no evidence that proportional
hazards assumptions were violated. For strokes ascertained from
death certificates alone, we took the date of diagnosis to be the date
of death. Since this could create a potential bias, we first examined
the association between physical activity and stroke risk, excluding
alumni with strokes determined from death certificates. We counted
only cases of stroke ascertained from the 1988 questionnaire in
which date of diagnosis was known. The findings from these
analyses were similar to those from analyses in which all strokes (ie,
determined from the 1988 questionnaire or death certificate) were
included. Therefore, we present our findings only from analyses that
combined strokes ascertained from both sources.
We first modeled rate ratios (relative risks) of stroke as a function
of total energy expenditure and age. We then proceeded to adjust
additionally for other predictors of stroke in these data: cigarette
smoking, alcohol consumption, and early parental death. Since
age-adjusted and multivariate analyses yielded similar findings, only
results from the latter are presented. We calculated 95% CIs for
estimated relative risks and used 2-tailed tests of significance.
In secondary analyses, we examined the association between total
energy expenditure and stroke risk separately for 2 time periods
(chosen so that there would be approximately the same number of
events in each period): 1977 to 1984 and 1985 to 1990, and for 3 age
groups: ,65, 65 to 74, and $75 years at study entry. We also
separately analyzed a subgroup of men at lower risk of stroke: men
who did not smoke, consumed ,200 g/wk of alcohol, and whose
parents did not die before age 65 years.
When analyzing the components of physical activity, we included
indicator terms for categories of walking, stair climbing, nonvigorous
(,6 METs) energy expenditure, and vigorous ($6 METs) energy
expenditure in multivariate models. To assess the effects of light activity
and activity of at least moderate intensity, we conducted parallel
analyses with energy expenditure dichotomized at 4.5 instead of 6.0
METs. Finally, we investigated the effects of walking and stair climbing
among only men reporting no sports or recreation in 1977.
Results
At study entry, alumni were aged 58 years on average (range,
43 to 88 years) (Table 1). Their prevalence of smoking,
16.9%, was much lower than in the general population of that
October 1998
2051
Characteristic
Mean age, years (6SD)
58.0 (68.95)
Cigarette habit, %
Nonsmoker
83.1
8.5
8.4
Alcohol consumption, %
,50 g/wk
27.2
50,200 g/wk
37.1
$200 g/wk
35.7
65.8
29.8
4.4
23.0
22.5,23.5
14.4
23.5,24.5
19.1
24.5,26.0
20.4
$26.0
23.1
Physician-diagnosed hypertension, %
Physician-diagnosed diabetes mellitus, %
20.1
3.9
31.0
10001999
28.7
20002999
18.2
30003999
10.2
$4000
11.9
2052
Physical Activity
Component
Incidence
Rate
No. of
(per
Events 10 000)
Multivariate Relative
Risk (95% CI)
Incidence
Rate
No. of
(per
Events 10 000)
Physical Activity
Component
Multivariate Relative
Risk (95% CI)
128
34.5
1.00 (referent)
None
248
33.2
1.00 (referent)
5,10
81
34.1
1.06 (0.801.40)
1,250
33
30.2
0.92 (0.641.34)
10,20
105
32.9
1.01 (0.771.31)
250,600
28
28.2
0.83 (0.561.23)
64
23.6
0.71 (0.520.96)
600,1400
30
27.7
0.87 (0.591.27)
$1400
39
29.1
$20
0.89 (0.631.25)
116
34.8
1.00 (referent)
10,20
78
33.3
0.95 (0.711.27)
None
206
35.1
1.00 (referent)
20,35
59
25.0
0.71 (0.520.98)
1,250
56
32.0
0.88 (0.651.19)
125
31.6
0.97 (0.741.25)
250,600
27
21.6
0.60 (0.400.90)
600,1400
40
25.7
0.72 (0.511.03)
$1400
49
31.3
$35
Activities at ,6 METs, kcal/wk
None
221
34.3
1.00 (referent)
1,250
41
30.7
0.90 (0.641.26)
250,600
30
24.0
0.69 (0.471.01)
600,1400
40
29.1
0.86 (0.611.21)
$1400
46
29.2
0.86 (0.631.19)
0.89 (0.641.23)
217
33.8
1.00 (referent)
1,250
55
30.6
0.90 (0.671.22)
250,600
27
22.9
0.67 (0.451.02)
600,1400
35
27.0
0.82 (0.561.18)
$1400
44
33.9
1.03 (0.731.44)
Discussion
In these prospective data, physical activity was associated
with decreased risk of stroke in men. With higher levels of
energy expenditure up to 3000 kcal/wk, risk declined
steadily; beyond this, however, the association weakened. We
observed similar findings even in older individuals. What
kinds of activities were beneficial? The data indicated that
walking $20 km/wk was associated with significantly lower
risk, independent of other physical activity components.
Climbing stairs and activities of at least moderate intensity
($4.5 METs) each showed U-shaped relations to stroke risk,
with the risk being significantly lower at the nadir of the
curve. Light-intensity activities (,4.5 METs), however, were
unrelated to stroke risk. Furthermore, men who participated
in recreational activities experienced lower stroke rates than
those who only walked or climbed stairs but did not engage
in recreational activities.
It is unclear why stroke incidence rates exhibited a
U-shaped relation to physical activity in this study group.
Two of 3 randomized trials specifically testing exercise of
different intensities suggest that higher-intensity physical
activity is less effective in decreasing blood pressure than
lower intensity activity.43,44 This could plausibly explain our
observations. We did, however, explore whether the
October 1998
2053
Acknowledgments
This study was supported by grants from the National Heart, Lung,
and Blood Institute (HL 34174) and the National Cancer Institute
2054
References
1. National Center for Health Statistics. Health, United States, 1995.
Hyattsville, Md: Public Health Service; 1996.
2. Kistler JP, Ropper AH, Martin JB. Cerebrovascular diseases. In:
Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper
DL, eds. Harrisons Principles of Internal Medicine. New York, NY:
McGraw-Hill, Inc; 1994:22332256.
3. Moore S. Physical activity, fitness, and atherosclerosis. In: Bouchard C,
Shephard RJ, Stephens T, eds. Physical Activity, Fitness, and Health:
International Proceedings and Consensus Statement. Champaign, Ill:
Human Kinetics Publishers; 1994:570 578.
4. Fagard RH, Tipton CM. Physical activity, fitness, and hypertension. In:
Bouchard C, Shephard RJ, Stephens T, eds. Physical Activity, Fitness,
and Health: International Proceedings and Consensus Statement.
Champaign, Ill: Human Kinetics Publishers; 1994:633 655.
5. Paffenbarger RS Jr, Williams JL. Chronic disease in former college
students: early precursors of fatal stroke. Am J Public Health. 1967;57:
1290 1299.
6. Paffenbarger RS Jr, Hyde RT, Wing AL, Steinmetz CH. A natural history
of athleticism and cardiovascular health. JAMA. 1984;252:491 495.
7. Salonen JT, Puska P, Tuomilehto. Physical activity and risk of myocardial
infarction, cerebral stroke and death. Am J Epidemiol. 1982;115:526537.
8. Herman B, Schmitz PIM, Leyten ACM, van Luijk JH, Frenken CWGM, Op
de Coul AAW, Schulte BPM. Multivariate logistic analysis of risk factors for
stroke in Tilburg, the Netherlands. Am J Epidemiol. 1983;118:514525.
9. Lapidus L, Bengtsson C. Socioeconomic factors and physical activity in
relation to cardiovascular disease and death: a 12 year follow up of
participants in a population study of women in Gothenburg, Sweden. Br
Heart J. 1986;55:295301.
10. Wannamethee G, Shaper AG. Physical activity and stroke in British
middle aged men. BMJ. 1992;304:597 601.
11. Shinton R, Sagar G. Lifelong exercise and stroke. BMJ. 1993;307:
231234.
12. Lindenstrm E, Boysen G, Nyboe J. Lifestyle factors and risk of cerebrovascular disease in women: the Copenhagen City Heart Study. Stroke.
1993;24:1468 1472.
13. Hheim LL, Holme I, Hjermann I, Leren P. Risk factors of stroke
incidence and mortality: a 12-year follow-up of the Oslo Study. Stroke.
1993;24:1484 1489.
14. Abbott RD, Rodriguez BL, Burchfiel CM, Curb JD. Physical activity in
older middle-aged men and reduced risk of stroke: the Honolulu Heart
Program. Am J Epidemiol. 1994;139:881 893.
15. Kiely DK, Wolf PA, Cupples LA, Beiser AS, Kannel WB. Physical
activity and stroke risk: the Framingham Study. Am J Epidemiol. 1994;
140:608 620.
16. Gillum RF, Mussolino ME, Ingram DD. Physical activity and stroke
incidence in women and men: the NHANES I Epidemiologic Follow-up
Study. Am J Epidemiol. 1996;143:860 869.
17. Sacco RL, Gan R, Boden-Albala B, Lin I-F, Kargman DE, Hauser WA,
Shea S, Paik MC. Leisure-time physical activity and ischemic stroke risk:
the Northern Manhattan Stroke Study. Stroke. 1998;29:380 387.
18. Paffenbarger RS Jr. Factors predisposing to fatal stroke in longshoremen.
Prev Med. 1972;1:522527.
19. Kannel WB, Sorlie P. Some health benefits of physical activity: the
Framingham Study. Arch Intern Med. 1979;139:857 861.
20. Menotti A, Seccareccia F. Physical activity at work and job responsibility
as risk factors for fatal coronary heart disease and other causes of death.
J Epidemiol Community Health. 1985;39:325329.
21. Menotti A, Keys A, Blackburn H, Aravanis C, Dontas A, Fidanza F,
Giampaoli S, Karvonen M, Kroumhout D, Nedeljkovic S, Nissinen A,
Pekkanen J, Punsar S, Seccareccia F, Toshima H. Twenty-year stroke
mortality and prediction in twelve cohorts of the Seven Countries Study.
Int J Epidemiol. 1990;19:309 315.
22. Harmsen P, Rosengren A, Tsipogianni A, Wilhelmsen L. Risk factors for
stroke in middle-aged men in Goteborg, Sweden. Stroke. 1990;21:
223229.
23. Lindsted KD, Tonstad S, Kuzma JW. Self-report of physical activity and
patterns of mortality in Seventh-Day Adventist men. J Clin Epidemiol.
1991;44:355364.
24. Ellekjr EF, Wyller TB, Sverre JM, Holmen J. Lifestyle factors and risk
of cerebral infarction. Stroke. 1992;23:829 834.
25. US Department of Health and Human Services. Physical Activity and
Health: A Report of the Surgeon General. Atlanta, Ga: US Department of
Health and Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health Promotion;
1996:1 8, 85172, 175207.
26. Lee I-M, Paffenbarger RS Jr, Hsieh C-c. Time-trends in physical activity
among college alumni, 19621988. Am J Epidemiol. 1992;135:915925.
27. LaPorte RE, Cauley JA, Kinsey CM, Corbett W, Robertson R, BlackSandler R, Kuller LH, Falkel J. The epidemiology of physical activity in
children, college students, middle-aged men, menopausal females and
monkeys. J Chron Dis. 1982;35:787795.
28. LaPorte RE, Black-Sandler RB, Cauley JA, Link M, Bayles C, Marks B.
The assessment of physical activity in older women: analysis of the
interrelationship and reliability of activity monitoring, activity surveys,
and caloric intake/expenditure. J Gerontol. 1983;30:394 397.
29. Siconolfi SF, Lasater TM, Snow RCK, Carleton RA. Self-reported
physical activity compared with maximal oxygen uptake. Am J Epidemiol. 1985;122:101105.
30. Cauley JA, LaPorte RE, Sandler RB, Schramm MM, Kriska AM. Comparison of methods to measure physical activity in postmenopausal
women. Am J Clin Nutr. 1987;45:14 22.
31. Albanes D, Conway JM, Taylor PR, Moe PW, Judd J. Validation and
comparison of eight physical activity questionnaires. Epidemiology.
1990;1:6571.
32. Washburn RA, Smith KW, Goldfield SRW, McKinlay JB. Reliability and
physiologic correlates of the Harvard Alumni Activity Survey in a general
population. J Clin Epidemiol. 1991;44:1319 1326.
33. Ainsworth BE, Leon AS, Richardson MT, Jacobs DR, Paffenbarger RS
Jr. Accuracy of the College Alumnus Physical Activity Questionnaire.
J Clin Epidemiol. 1993;46:14031411.
34. Ainsworth BE, Haskell WL, Leon AS, Jacobs DR Jr, Montoye HJ, Sallis
JF, Paffenbarger RS Jr. Compendium of physical activities: classification
of energy costs of human physical activities. Med Sci Sports Exerc.
1993;25:71 80.
35. Taylor HL, Jacobs DR Jr, Schucker B, Knudsen J, Leon AS, Debacker G.
A questionnaire for the assessment of leisure time physical activities.
J Chron Dis. 1978;31:741755.
36. NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. Physical activity and cardiovascular health. JAMA. 1996;
276:241246.
37. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C,
Buchner D, Ettinger W, Heath GW, King AC, Kriska A, Leon AS,
Marcus BH, Morris J, Paffenbarger RS Jr, Patrick K, Pollock ML, Rippe
JM, Sallis J, Wilmore JH. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the
American College of Sports Medicine. JAMA. 1995;273:402 407.
38. Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of
heart attack risk in college alumni. Am J Epidemiol. 1978;108:161175.
39. Lee I-M, Paffenbarger RS Jr, Hsieh C-C. Physical activity and risk of
developing colorectal cancer among college alumni. J Natl Cancer Inst.
1991;83:1324 1329.
40. Lee I-M, Paffenbarger RS Jr, Hsieh C-C. Physical activity and risk of
prostatic cancer among college alumni. Am J Epidemiol. 1992;135:
169 179.
41. Cox DR. Regression models and life tables. J R Stat Soc (B). 1972;34:
187220.
42. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing
prevalence of overweight among US adults: the National Health and
Nutrition Examination Surveys, 1960 to 1991. JAMA. 1994;272:205211.
43. Hagberg JM, Montain SJ, Martin WH III, Ehsani AA. Effect of exercise
training in 60- to 69-year-old persons with essential hypertension. Am J
Cardiol. 1989;64:348 353.
44. Matsusaki M, Ikeda M, Tashiro E, Koga M, Miura S-i, Ideishi M, Tanaka
H, Shindo M, Arakawa K. Influence of workload on the antihypertensive
effect of exercise. Clin Exp Pharmacol Physiol. 1992;19:471 479.
45. Bronner LL, Kanter DS, Manson JE. Primary prevention of stroke.
N Engl J Med. 1995;333:13921400.
46. Whisnant JP, Wiebers DO, OFallon WM, Sicks JD, Frye RL. A
population-based model of risk factors for ischemic stroke: Rochester,
Minnesota. Neurology. 1996;47:1420 1428.