Background Recent trends toward increasing physical exercise,stopping cigarette smoking, and avoiding obesity may increaselongevity. We analyzed changes in the lifestyles of HarvardCollege alumni and the associations of these changes with mortality.
Methods Men who were 45 to 84 years of age in 1977 and who hadreported no life-threatening disease on questionnaires completedin 1962 or 1966 and again in 1977 were classified accordingto changes in lifestyle characteristics between the first andsecond questionnaires. We analyzed changes in their level ofphysical activity, cigarette smoking, blood pressure, and bodyweight, and the relation of these factors to mortality between1977 and 1985.
Results Of the 10,269 men, 476 died during this period (whichtotaled 90,650 man-years of observation). Beginning moderatelyvigorous sports activity (at an intensity of 4.5 or more metabolicequivalents) was associated with a 23 percent lower risk ofdeath (95 percent confidence interval, 4 to 42 percent; P =0.015) than not taking up moderately vigorous sports. Quittingcigarette smoking was associated with a 41 percent lower risk(95 percent confidence interval, 20 to 57 percent; P = 0.001)than continuing smoking, but with a 23 percent higher risk thanconstant nonsmoking. Men with recently diagnosed hypertensionhad a lower risk of death than those with long-term hypertension(relative risk, 0.75; 95 percent confidence interval, 0.55 to1.02; P = 0.057), as did men with consistently normal bloodpressure (relative risk, 0.52; 95 percent confidence interval,0.40 to 0.68; P<0.001). Maintenance of lean body mass wasassociated with a lower mortality rate than long-term, recent,or previous obesity. The associations between changes in lifestyleand mortality were independent and were largely undiminishedby age. Our findings on death from coronary heart disease mirroredthose on death from all causes.
Conclusions Beginning moderately vigorous sports activity, quittingcigarette smoking, maintaining normal blood pressure, and avoidingobesity were separately associated with lower rates of deathfrom all causes and from coronary heart disease among middle-agedand older men.
Physical-activity level, physical fitness, and other modifiablelifestyle characteristics may influence the risk of chronicdisease and premature death1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18.Changes in lifestyle may therefore promote optimal health andlongevity. Harvard College archives from 1916 through 1950 providedphysical, social, athletic, and other data on thousands of formerstudents whom we studied to determine whether the men's characteristicsat college age predisposed them to chronic diseases, particularlycoronary heart disease, later in life19. Follow-up questionnairesmailed to alumni in the 1960s and 1970s reaffirmed the associationbetween adequate higher levels of physical activity and longersurvival, and also the associations between sedentary behavior,cigarette smoking, hypertension, and obesity and earlier death4,5.In this study, we examined data on Harvard alumni to determinewhether changes in exercise habits and other personal characteristicswere associated with lower rates of death from all causes andfrom coronary heart disease.
Methods
The Study Population
To assess changes in lifestyle, we included only alumni whohad responded to mailed questionnaires in 1962 or 1966 and againin 1977. Men who reported on either questionnaire that a physicianhad given them a diagnosis of coronary heart disease, stroke,chronic obstructive respiratory disease, diabetes, or cancerwere excluded in order to avoid bias in the analysis of theinfluence of physical activity on subsequent mortality. We analyzedassociations between the men's personal and lifestyle characteristicsand mortality from 1977 through 1985 and the relation of thesecharacteristics to estimated increments in longevity (up tothe age of 85). We also examined changes in these characteristicsbetween the first and second questionnaires for any associationssuch changes had with subsequent mortality (between 1977 and1985) and length of life.
In the two questionnaires the participants reported detailedinformation covering most of their lives. In 1962 or 1966, 21,582(68 percent) of 31,697 men known to be alive who had enteredcollege between 1916 and 1950 returned interpretable questionnaires.Of the 19,359 who were still alive in 1977, 14,800 (76 percent)responded again that year. During follow-up, men who reached85 years of age were dropped from further assessment, and longevitywas measured only up to that arbitrarily chosen age.
The questionnaires asked about physical activity, cigarettesmoking, specific diseases diagnosed by physicians, body size,and parental disease and death (an index of familial and hereditaryinfluences). Weekly lists of deaths from the Harvard AlumniOffice enabled us to obtain death certificates and identifycauses of death. Fewer than 1 percent of the alumni includedin the study were lost to follow-up.
Assessment of Physical Activity
On both questionnaires, alumni reported how many city blocksthey walked daily, how many flights of stairs they climbed daily,and the type, frequency, and duration of their participationin sports or recreational activities in hours per week. Fromthese data a physical-activity index was computed in kilocaloriesper week, in which walking 1 mile (1.6 km) was assigned a valueof 100 kcal and climbing five flights of stairs (100 stairs),40 kcal; sports and recreation were classified according tointensity at 5, 7.5, or 10 kcal per minute. The physical-activityindex was considered an indicator rather than an absolute measureof energy expenditure.
We further classified sports and other recreational activitiesaccording to intensity and duration, defining light sports activityas requiring less than 4.5 metabolic equivalents (METs) andmoderately vigorous activity as requiring 4.5 or more METs.One MET is defined as the energy expended per minute while sittingquietly and is equivalent to 3.5 ml of oxygen uptake per kilogramof body weight per minute for an adult weighing 70 kg. Activitieswere designated light or moderately vigorous on the basis ofgenerally accepted MET values20,21,22. The light activitiesmost commonly reported were golf, walking for pleasure, anda combination of gardening, housework, and carpentry. The mostcommon moderately vigorous sports activities were swimming;tennis, squash, racquetball, or handball; and jogging or running.We also analyzed moderately vigorous sports activity in termsof hours per week.
Other Lifestyle Characteristics
To study the influence of such continuous variables as cigarettesmoking and body-mass index, we created three categories thatmight reveal any gradient in the risk of death. For cigarettesmoking in 1977, we grouped men who smoked a pack (20 cigarettes)or more per day, men who smoked less than a pack daily, andnonsmokers. In terms of blood-pressure status in 1977, we dividedthe sample into men with hypertension diagnosed by a physician,normotensive men whose systolic blood pressure recorded in collegewas 130 mm Hg or more, and normotensive men whose systolic bloodpressure in college was less than 130 mm Hg. The body-mass (Quetelet's)index was computed as the weight in kilograms divided by thesquare of the height in meters. Alumni were classified as havingan index of 26, 24 to 25, or <24. The sample was dividedwith regard to parental death into groups of men both of whoseparents had died before 65 years of age by 1977, those withone parent who had died before the age of 65, and those withboth parents living.
Statistical Analysis
Data on physical-activity levels and other lifestyle characteristicsreported in 1977, and changes in these factors between 1962or 1966 and 1977, were studied for any association with mortalityfrom all causes and mortality from coronary heart disease duringthe nine-year period from 1977 through 1985. Mortality ratesper 10,000 man-years of observation were adjusted by the indirectmethod for age (in five-year groups) and other confounding factorsamong the groups being compared. The rates thus calculated forvarious subgroups of alumni provided the basis for determiningrelative risks of death, with the death rate among men whoseclassification was deemed to entail the highest risk or thelowest risk used as the reference category, depending on theanalysis.
Estimates of attributable risk for each category of a variableas of 1977 were computed as potential percentage reductionsin population death rates, adjusted for age and each of theother categories considered. The multivariate analyses usedfor estimating relative and attributable risks of death andadded years of life potentially attributable to favorable changesin characteristics were based on proportional-hazards modelswith Poisson regression methods23.
To assess the associations between changes in lifestyle andmortality, we defined four status categories (remained at highrisk, changed from low to high risk, changed from high to lowrisk, remained at low risk) and examined the mortality ratesfor each category. The association between each characteristicand mortality was assessed with the relations of age and theother characteristics to mortality held constant. The Mantelextension of the Mantel-Haenszel test was used to determinethe significance of mortality trends across categories of selectedcharacteristics24. We computed years of life that may have beengained among men who adopted a more favorable lifestyle, ascompared with men whose lifestyle entailed a high risk25. Estimatesof significance were derived from two-tailed tests.
Results
The eligible population numbered 10,269 alumni who ranged from45 to 84 years of age (mean [±SD], 57.5 ±8.8)in 1977. There were 476 deaths during 90,650 man-years of observationin the nine-year follow-up period from 1977 through 1985. Therewere 208 deaths from cardiovascular disease (130 from coronaryheart disease), 156 from cancer, 63 from other natural causes,45 from trauma, and 4 from unknown causes.
Lifestyle and Mortality from All Causes
Table 1 shows age-adjusted rates and relative risks of deathfrom any cause during follow-up according to lifestyle and personalcharacteristics as reported on the questionnaires returned in1977. After more than a decade, these results echoed findingsfrom similar questionnaires returned by the same men in 1962or 1966 with follow-up through 19784,5. This consistent patternreaffirms the inverse relation between the level of physicalactivity and the risk of premature death from any cause. Allmajor trends related to physical-activity level (i.e., the associationbetween lower death rate and increases in walking, stair climbing,moderately vigorous sports activity, and physical-activity index)were statistically significant.
Table 1. Age-Adjusted Rates and Relative Risks of Death from All Causes among 10,269 Harvard Alumni from 1977 through 1985, According to Patterns of Physical Activity and Other Characteristics in 1977.
Gradients of benefit were consistent throughout, except forlight sports activity (fewer than 4.5 METs), which was not associatedwith a lower mortality from all causes, and the physical-activityindex, for which the intermediate levels of energy expenditure(500 to 3499 kcal per week) were associated with similar deathrates. Yet the most active men, who expended 3500 kcal per weekor more, had half the risk of death of the least active (lessthan 500 kcal per week). Moreover, when the men were arbitrarilydivided according to the physical-activity index at 2000 kcalper week, the death rate associated with a low index was 57.1per 10,000 man-years and that associated with a high index only45.1, giving a 21 percent lower relative risk for the more active(95 percent confidence interval, 4 to 35 percent; P = 0.015).
The 1977 questionnaire responses indicated a notably high proportionof men who participated in moderately vigorous sports activity;they accounted for three fourths of the man-years assessed --a near reversal of the 1962 or 1966 response4,5. From 1977 through1985, the relative risk of death was halved among the quarterof the alumni who reported three or more hours of moderatelyvigorous sports activity per week, as compared with the quarterwho did not engage in such sports or recreational activity.
Table 1 also shows a direct association between death rates(and relative risks of death) and high-risk characteristics,particularly cigarette smoking, hypertension, and a high body-massindex. A reversed J-shaped curve for mortality risk was seenfor the high and low extremes of the body-mass index as comparedwith intermediate values. Early parental death was largely unrelatedto mortality as the alumni neared the age of 65 years themselves.
Table 2 shows the relative and attributable risks of death associatedwith the presence and absence of each of the five adverse personalcharacteristics -- sedentary living, cigarette smoking, hypertension,overweight for height (a high body-mass index), and early parentaldeath -- with adjustments for differences in age and in eachof the other four characteristics. More detailed adjustmentsfor cigarette-smoking status (never, former, light, and heavy)made little difference in the results for the other characteristics.During the follow-up period, the sedentary alumni (those witha physical-activity index of less than 2000 kcal per week) hada 25 percent higher risk of death than more active men, smokershad an 87 percent higher risk than nonsmokers, men with hypertensionhad a 69 percent higher risk than men with normal blood pressure,and the more obese men had a 31 percent greater risk than theleaner men, but a history of early death in one or both parentshad little relation to longevity. Those with one or more ofthese adverse lifestyle characteristics, who contributed 83percent of the man-years of observation, were at 64 percentgreater risk of mortality from all causes during the nine-yearfollow-up period than the men with none of these adverse characteristics.
Table 2. Relative and Attributable Risks of Death from All Causes among 10,269 Harvard Alumni from 1977 through 1985, According to Adverse Lifestyle Characteristics in 1977.
Sedentary living was further divided (Table 2) into low levelsof walking or stair climbing and lack of moderately vigoroussports activity. The mortality rates associated with each factorhave been adjusted for differences in the others as well asfor age and the other four adverse characteristics. The subgroupanalysis shows that men who walked less than nine miles perweek had a 16 percent higher risk of death than those who walkedmore (P not significant) and those who climbed fewer than 20flights of stairs per week had a 23 percent higher risk thanthose who climbed more. Men who did not engage in moderatelyvigorous sports activity had a 44 percent higher risk of deaththan those who did.
Estimates of Attributable Risk
The "population-attributable risk" is an estimate of the percentagereduction in the death rate that might have occurred in thetotal group of 10,269 alumni (some with and some without high-riskcharacteristics) if all the men with specified adverse characteristicshad converted them to healthful levels and if all who alreadyhad favorable characteristics had maintained them. Estimatesof attributable risk require the assumption of a cause-and-effectrelation, persistence of lifestyle patterns through the follow-upperiod, and equal distribution of any potential confoundingfactors among the groups being compared. Estimates of attributablerisk are given in Table 2. Notably, if all the men had playedmoderately vigorous sports, the death rates might have been12 percent lower than was actually the case, and total abstinencefrom cigarettes might have reduced the overall death rate by11 percent. If all five of the adverse lifestyle factors listedhad been completely absent, the death rate from all causes duringthe nine years might have been 41 percent lower than that observed.Expressed differently, 195 of the 476 deaths might have beenpostponed.
Lifestyle Characteristics and Mortality from Coronary Heart Disease
There were 130 deaths from physician-diagnosed coronary heartdisease during the follow-up period. When analyzed as in Table 2,sedentary alumni were at 36 percent higher risk of deathfrom coronary heart disease (95 percent confidence interval,-8 to 99 percent) than active men. Men who climbed fewer than20 flights of stairs per week (one flight consists of 20 steps)and did not engage in moderately vigorous sports activity wereat 56 percent (95 percent confidence interval, 7 to 128 percent)and 51 percent (95 percent confidence interval, 2 to 123 percent)higher risk than men who climbed more stairs or engaged in moderatelyvigorous activity. Cigarette smoking was associated with a doubledrisk of death from coronary heart disease (P<0.001), as washypertension (P<0.001); overweight for height was associatedwith a 55 percent increase in risk (95 percent confidence interval,5 to 128 percent); early parental death was associated witha 64 percent increase (95 percent confidence interval, 15 to134 percent); and having at least one of these adverse characteristicswas associated with an added risk of 151 percent (95 percentconfidence interval, 23 to 414 percent).
Estimates of the population-attributable risk during follow-upwith the elimination of selected characteristics were as follows:not engaging in moderately vigorous sports, 14 percent; cigarettesmoking, 13 percent; hypertension, 20 percent; overweight forheight, 11 percent; and early parental death, 20 percent. Inthe absence of all these adverse characteristics, 58 percentof these deaths from coronary heart disease (95 percent confidenceinterval, 40 to 70 percent) might have been delayed.
Changes in Lifestyle and Mortality from All Causes
Table 3 shows the association of favorable changes in lifestylebetween 1962 or 1966 and 1977 with rates of death from all causesfrom 1977 through 1985. Forty-one percent of the man-years wascontributed by men who did not report enough physical activityto reach an index of 2000 kcal or more per week at either assessment.Another 16 percent was contributed by men who dropped belowthat index level by 1977, 20 percent by men who increased theiractivity to favorable levels, and 24 percent by men who hadbeen active at the level of 2000 kcal per week at both assessments.Although the difference was not significant, perhaps becauseof the small numbers, the alumni who increased their level ofactivity through a combination of walking, climbing stairs,and engaging in sports activity had a 15 percent lower deathrate than the men who continued to be sedentary.
Table 3. Rates and Relative Risks of Death from All Causes among 10,269 Harvard Alumni from 1977 through 1985, According to Changes in Patterns of Physical Activity and Other Characteristics between 1962 or 1966 and 1977.
The findings for moderately vigorous sports activity resemblethose for the physical-activity index, even though the formerwas defined by intensity ( 4.5 METs) and the latter in termsof kilocalories per week. Men who discontinued moderately vigoroussports activity had a 15 percent higher risk of mortality thanmen who had never reported such activity (P not significant).Thirty-eight percent of the men, however, took up moderatelyvigorous sports activity, and they had a 23 percent lower riskof mortality, close to the 29 percent lower risk for men whohabitually engaged in moderately vigorous sports activity.
Hardly anyone took up cigarette smoking during the period betweenthe questionnaires. Sixteen percent of the men continued tosmoke; 18 percent abandoned smoking, joining the 64 percentwho were nonsmokers, for a total of 82 percent nonsmokers in1977. Men who quit smoking had a 41 percent lower death rate,but even this substantial lowering of mortality did not reachthe level for nonsmokers, which was half that for persistentsmokers.
Alumni in whom hypertension developed during the period betweenquestionnaires amassed more man-years (13 percent) than themen in whom hypertension developed earlier (8 percent), butthey had a lower relative risk of mortality from all causes(0.75). Risk for the men who continued to have normal bloodpressure was half that for those with long-term hypertension.
The risk of death from all causes was higher for men who werepersistently overweight for height, for those whose body-massindex increased to 26 or more, and for those whose index droppedbelow 26, as compared with those whose body-mass index remainedbelow that level. Normal-weight alumni had a 23 percent lowerrisk of mortality than the persistently overweight.
The associations of increases in the physical-activity index,taking up moderately vigorous sports activity, quitting cigarettesmoking, and maintaining normal blood pressure with age-specificmortality from all causes are shown in Figure 1. Although manyof the specific comparisons were not statistically significant,the trends of the associations are apparent. The differencein the risk of death associated with an increase in the physical-activityindex changed from a 55 percent lower risk to a 10 percent higherrisk as age increased, but taking up moderately vigorous sportsactivity conferred a steady advantage of 28, 31, 26, and 21percent from the youngest to the oldest age group. Both quittingcigarette smoking and maintaining normal blood pressure weremore strongly associated with lower mortality from all causesin the older age groups than in the youngest.
Figure 1. Rates and Relative Risks of Death from All Causes among 10,269 Harvard Alumni, According to Age in 1977 and Changes in Patterns of Physical Activity and Other Characteristics between 1962 or 1966 and 1977.
Relative risks are expressed in relation to men who did not make the change, as indicated in each panel. The men ranged in age from 45 to 84 years in 1977. The follow-up period, from 1977 through 1985, totaled 90,650 man-years of observation. Relative risks and 95 percent confidence intervals are shown above the bars.
Changes in Lifestyle and Mortality from Coronary Heart Disease
The risk of death from coronary heart disease was examined accordingto changes in lifestyle, in analyses that paralleled those summarizedin Table 3. Again, the small numbers of deaths from coronaryheart disease limited the statistical power of the observations.Alumni who increased their physical-activity index to 2000 kcalor more per week had a 17 percent lower risk of death from coronaryheart disease than those who remained more sedentary (P = 0.507).But men who took up moderately vigorous activity had a 41 percentlower risk than those who continued not to engage in such activity(P = 0.044). Men who quit cigarette smoking were at 44 percentlower risk than continuing smokers (P = 0.052). Men who maintainednormal blood pressure were at 49 percent lower risk than thosewith hypertension (P<0.001). And the men who continued tobe lean had a 41 percent lower risk than those whose body-massindex increased to at least 26 (P = 0.085).
Changes in Lifestyle and Longevity
Table 4 gives estimates of the years of life added for alumniwho reported adopting low-risk characteristics between 1962or 1966 and 1977, based on their rates of mortality from allcauses from 1977 through 1985. The data represent estimatesof the extension of life associated with specific favorablelifestyle characteristics, adjusted for differences in eachof the other characteristics listed and for early parental mortality.The gains shown are according to 10-year age groups and forthe composite total, with added years estimated only up to theage of 85.
Table 4. Additional Years of Life up to the Age of 85 Associated with Adoption or Maintenance of a Favorable Physical-Activity Level and Other Characteristics between 1962 or 1966 and 1977, as Estimated from Mortality Rates among 10,269 Harvard Alumni from 1977 through 1985.
Age adjustments made for the entire group of men from 45 to84 years of age showed that added years of life were associatedwith specific changes in lifestyle. Noteworthy were an additional0.72 year associated with taking up moderately vigorous sportsactivity, 1.46 associated with quitting cigarette smoking, andan impressive 2.49 years associated with both changes.
Discussion
The questionnaire responses of the Harvard alumni whom we studiedreflected recent trends in the United States toward increasedleisure-time exercise, abandonment of cigarette smoking, andcontrol of body weight22. The changes in lifestyle made by thesemen during the period between the questionnaires and their correspondingrates of mortality from all causes and from coronary heart diseasefrom 1977 through 1985 fit the hypothesis that these trendshave a favorable effect on mortality. In particular, the hundredsof aging alumni who took up moderately vigorous sports activityhad a substantial reduction in mortality from all causes (23percent) and from coronary heart disease (41 percent) as comparedwith their less vigorous classmates. However, the data do notprove a cause-and-effect relation between the adoption of amore active lifestyle and a lower death rate.
Our observations are reminiscent of earlier findings4,5,26,27that former varsity athletes who discontinued their sports activitieshad higher rates of disease and death thereafter than theirteammates who continued energetic exercise. Moreover, in anearly example of favorable change, alumni who had avoided athleticsas college students but subsequently took up a more active lifestylehad the same low risk as classmates who had been vigorouslyactive all along. The testimony of these patterns -- derivedfrom more than 300,000 man-years of observation (since collegeentrance) -- supports the thesis that a reduced risk of deathfrom coronary heart disease and from all causes, leading tolonger life, results from an adequate exercise program.
Although in 1977 the 10,269 alumni were free of diagnosed chronicdisease that might limit their physical activity, includingsports activity, some men may have had subclinical or undiagnoseddisease that, in turn, resulted in both sedentary habits andpremature death. In observational studies, such selective influencescannot be eliminated entirely, as might be possible in appropriatelydesigned clinical trials. But the impracticality of controlledtrials that would assess the health effects of a physicallyactive way of life makes such an undertaking virtually impossible.Further limitations of our study result from incomplete questionnairereturns (response rates of 68 to 76 percent) and possible confoundingdue to any differences in dietary intake between active andinactive men. Nonrespondents to the 1977 questionnaire had atwo thirds higher death rate than respondents through 1985 (206.8vs. 123.3 per 10,000 man-years). Dietary data collected in thequestionnaires were insufficient for meaningful analysis.
Data are unavailable on intermediate variables -- such as dyslipoproteinemia,hyperinsulinemia, hyperglycemia, cardiac dysfunction, and actualblood pressure levels -- that might provide a causal pathwaybetween physical inactivity and higher death rates from coronaryheart disease and from all causes28. In addition, the relativeimportance of the intensity as compared with the quantity ofexercise for optimal health benefit is not easily determined,since men who engaged in moderately vigorous sports activitywere also those who had a higher physical-activity index. Yetin earlier analyses,26,29,30 the lower risk of death associatedwith a physically active lifestyle was even lower among themen who engaged in moderately vigorous sports activity eachweek. Although the Multiple Risk Factor Intervention Trial showedlittle or no added benefit of exercising beyond a moderate level,8British civil servants had lower rates of coronary heart diseaseand death only when they engaged in moderately vigorous recreationalactivity1,13,31. What kinds of physical activity should be prescribed,how much, how intense, and for whom if optimal health and longevityare to be achieved remain unanswered questions that requirefurther clarification.
Supported by grants from the National Heart, Lung, and BloodInstitute (R01 HL 34174) and the National Cancer Institute (R01CA 44854).
Source Information
From the Division of Epidemiology, Stanford University School of Medicine, Stanford, Calif. (R.S.P., R.T.H., D.L.J., J.B.K.), and the Department of Epidemiology, Harvard School of Public Health, Boston (R.S.P., A.L.W., I-M.L.).
Address reprint requests to Dr. Paffenbarger at the Department of Health Research and Policy, HRP Bldg., Rm. 113, Stanford University School of Medicine, Stanford, CA 94305-5092.
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26, 24 to 25, or <24. The sample was divided with regard to parental death into groups of men both of whose parents had died before 65 years of age by 1977, those with one parent who had died before the age of 65, and those with both parents living. 
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