Effects of Walking on Mortality among Nonsmoking Retired Men
Amy A. Hakim, M.S., Helen Petrovitch, M.D., Cecil M. Burchfiel, Ph.D., G. Webster Ross, M.D., Beatriz L. Rodriguez, M.D., Ph.D., Lon R. White, M.D., Katsuhiko Yano, M.D., J. David Curb, M.D., and Robert D. Abbott, Ph.D.
Background The potential benefit of low-intensity activity interms of longevity among older men has not been clearly documented.We examined the association between walking and mortality ina cohort of retired men who were nonsmokers and physically capableof participating in low-intensity activities on a daily basis.
Methods We studied 707 nonsmoking retired men, 61 to 81 yearsof age, who were enrolled in the Honolulu Heart Program. Thedistance walked (miles per day) was recorded at a base-lineexamination, which took place between 1980 and 1982. Data onoverall mortality (from any cause) were collected over a 12-yearperiod of follow-up.
Results During the follow-up period, there were 208 deaths.After adjustment for age, the mortality rate among the men whowalked less than 1 mile (1.6 km) per day was nearly twice thatamong those who walked more than 2 miles (3.2 km) per day (40.5percent vs. 23.8 percent, P = 0.001). The cumulative incidenceof death after 12 years for the most active walkers was reachedin less than 7 years among the men who were least active. Thedistance walked remained inversely related to mortality afteradjustment for overall measures of activity and other risk factors(P = 0.01).
Conclusions Our findings in older physically capable men indicatethat regular walking is associated with a lower overall mortalityrate. Encouraging elderly people to walk may benefit their health.
The benefits of low-intensity activity in reducing the riskof cardiovascular disease and increasing longevity have notbeen clearly identified.1,2,3,4,5,6 Even less is known aboutthe effects of such activities in older people. We undertookthis study to examine the association between walking and mortalityafter adjustment for several concomitant risk factors. Specialattention was given to a cohort of older nonsmoking men whowere retired and physically capable of participating in low-intensityactivities on a daily basis.
Methods
Study Population and Procedures
Since 1965, the Honolulu Heart Program has followed 8006 menof Japanese ancestry living on the island of Oahu, Hawaii, forthe development of cardiovascular disease and cause-specificmortality.7,8 At the time of study enrollment, when the subjectswere 45 to 68 years old, they received a complete physical examination.The procedures followed were in accordance with institutionalguidelines and approved by the Kuakini Medical Center Researchand Institutional Review Committee. Informed consent was obtainedfrom the study participants.
The follow-up period for this study began at the time of a base-lineexamination, which occurred between 1980 and 1982, when walkingwas first assessed. The sample comprised 1379 members of a cohortof men who were among the original participants in the CooperativeLipoprotein Phenotyping Study.9 That study and the sample includedin this report have been described elsewhere.10
After the base-line examination, 12 years of follow-up wereavailable in which to assess the relation between the distancewalked and the risk of death on the basis of comprehensive surveillanceof death certificates, hospital admissions, and obituary notices.As of 1990, 62 of the 8006 men in the original cohort had movedoff the island of Oahu, resulting in an out-migration rate ofabout 1 per 1000 men per year. The current survival status ofonly five men is unknown.
At the time the follow-up began (1980 to 1982), the men wereasked about the average distance they walked per day. Overallmeasures of activity at a variety of intensities were also assessedby recording the number of hours per day spent at each of fivelevels of activity with the use of questionnaires similar tothose of the Framingham4 and Puerto Rico11 heart studies. Thefive levels of activity were basal (sleeping or lying down),sedentary (sitting or standing), slight (e.g., casual walking),moderate (e.g., light carpentry or gardening), and heavy (e.g.,lifting or shoveling).
Only physically capable men were included in this study. Suchmen were included for follow-up if they reported undertakingat least one hour of slight, moderate, or heavy activity ona daily basis. All the men also indicated that they were retired.Men who were working full time or part time and those seekingemployment were excluded from follow-up. In addition, becausecigarette smoking is known to confound the relation betweenphysical activity and mortality,12,13,14,15 only nonsmokingmen were included in the study. After the exclusions, 707 men,61 to 81 years old, remained in the study sample; their averageage (±SD) was 68.9±5.1 years.
Statistical Analysis
To help isolate the independent effect of the distance walkedon overall mortality, the statistical analysis included adjustmentsfor several possible risk factors. These included age, concentrationsof total and high-density lipoprotein (HDL) cholesterol, bloodpressure, whether there was diabetes (on the basis of the medicalhistory or the use of insulin or oral hypoglycemic therapy),and alcohol intake. With the use of 24-hour dietary-recall methods,16nutritional risk factors were recorded, including total caloriesconsumed per day, the percentage of calories from fat, protein,and carbohydrates, and the strength of the subjects' preferencefor a Japanese diet (calculated as a percentage of foods consumed).Further description of the risk factors is provided elsewhere.7,8,16
Efforts to examine the effects of the distance walked per dayon mortality also included adjustments for an overall physical-activityindex calculated as a weighted sum of the number of hours spentat each of the five activity levels. In general, the highervalues of the index corresponded to more active lifestyles,whereas lower indexes corresponded to lifestyles that were moresedentary.4,11,15,17 The physical-activity index provided ameans of isolating an independent relation between walking andmortality by adjusting for the overall intensity of activitythat might coexist with the various distances walked.
To describe the way the distance walked might vary with theoverall physical-activity index and other confounding risk factors,we calculated age-adjusted means for each of the factors acrossthe ranges of distances walked (in miles per day). The proceduresfor adjustment were based on analysis-of-covariance methodsthat used general linear and logistic-regression models.18
Among the ranges of distance walked, the cumulative incidenceof mortality was also derived from estimated Kaplan–Meiersurvival curves19 and calculated as a cumulative percentageof deaths across the 12 years of follow-up. Proportional-hazardsregression models20 were also used to examine the independenteffect of walking on the risk of death and to provide estimatesof the relative risk among the ranges of distance walked. Allreported P values were based on two-sided tests of significance.
Results
Among the 707 men included in this study, the average (±SD)distance walked was 1.8±1.3 miles (2.9±2.1 km)per day. All the men participated in at least 1 hour of slightactivity on a daily basis (4.5±1.8 hours on average).Most of the men (589) participated in at least 1 hour of moderatedaily activity (2.9±1.7 hours on average), whereas only45 reported undertaking any heavy activity on a daily basis(1.5±0.9 hours on average).
During the 12 years of follow-up, there were 208 deaths. Thirty-threewere due to coronary heart disease, 19 to stroke, 68 to cancer,and 88 to other causes. The median time to death was seven years.
Table 1 shows the unadjusted and age-adjusted cumulative mortalityover the 12-year follow-up period among the men according tothe range of distance walked per day. For the men who walkedless than 1 mile (1.6 km) per day, the unadjusted mortalityrate was 43.1 deaths per 100 men. For the men who walked morethan 2 miles (3.2 km) per day, the unadjusted mortality wasmore than halved (21.5 per 100). The 12-year cumulative mortalityrate was significantly lower among the men who walked a mileor more per day than among those who walked shorter distances(P<0.001). Adjustment for age had a negligible effect onthe observed incidence of death. When the distance walked wasmodeled as a continuous variable, it was positively relatedto a decreased risk of death (P<0.001 without adjustmentfor age and P = 0.002 after adjustment for age).
Table 1. Unadjusted and Age-Adjusted 12-Year Cumulative Mortality According to Distance Walked per Day.
The effects of walking on death due to coronary heart diseasecould not be adequately distinguished from its effects on deathdue to stroke, since mortality from each cause occurred tooinfrequently in the study sample. Nevertheless, walking appearedto protect against these events, although the findings werenot statistically significant. After the exclusion of the menwith known coronary heart disease and stroke at the base-lineexamination, 6.6 percent of those who walked the least diedof one of these causes in the course of follow-up, as comparedwith 2.1 percent of the men who walked more than two miles perday.
Cancer was the most common cause of death; 13.4 percent of themen who walked less than one mile per day died of cancer, ascompared with 5.3 percent of those who walked more than twomiles per day. The difference in the risk of cancer betweenthese groups was statistically significant both with and withoutadjustment for age (P = 0.01 and P = 0.02, respectively).
Figure 1 shows the overall cumulative incidence of mortalityfrom all causes over time according to ranges of distance walkedper day. Throughout most of the follow-up period there is aclear ordering of the incidence curves across the ranges ofdistance walked. Men who walked the least (<1 mile per day)had the highest incidence of death, followed by the men whowalked 1 to 2 miles per day and those who walked more than 2miles per day. The cumulative incidence of death in 12 yearsamong the most active walkers was reached in less than 7 yearsamong the men who were least active.
Figure 1. Cumulative Mortality According to Year of Follow-up and Distance Walked per Day.
To convert distances to kilometers, multiply by 1.609.
Table 2 shows the associations between the other risk factorsand the distance walked. As expected, the trend for the physical-activityindex was significant (P<0.001). In contrast, the distancewalked per day was unrelated to total cholesterol concentration,blood pressure, or alcohol intake. The body-mass index (theweight in kilograms divided by the square of the height in meters)and the concentration of HDL cholesterol increased, however,and the percentage of men with diabetes tended to decrease withincreases in the distance walked, although the trends were notsignificant. The distance walked was unrelated to the nutritionalvariables.
Table 2. Age-Adjusted Risk Factors at Base Line, According to Distance Walked per Day.
To help determine whether the risk of death could be attributedto an association between walking and the other risk factorslisted in Table 2, proportional-hazards regression models wereestimated to control for possible confounding influences ofthese factors. The results of these analyses are shown in Table 3,with comparisons of the expected risks of death for the rangesof distance walked per day.
Table 3. Relative Risk of Death According to Distance Walked per Day, with Adjustment for Age and for Other Risk Factors.
After adjustment for risk factors, the risk of death among themen who walked less than one mile per day was 1.8 times thatamong the men who walked more than two miles per day (P = 0.009).The risk of death among the men who walked the least (<1mile per day) was 50 percent greater than it was among the menwho walked 1 to 2 miles per day (P = 0.008). The risk of deathamong the men who walked 1 to 2 miles per day was also greaterthan that among the men who walked longer distances (>2 milesper day), although the difference was not statistically significant.
In addition to selecting men who were physically capable, wealso attempted to control for possible influences of preexistingillness and subclinical disease by excluding the men who diedwithin a year after follow-up began. The exclusions did littleto alter the findings.
The distance walked had a significant inverse relation withthe risk of death from cancer but not with the risk of deathfrom coronary heart disease or stroke. After adjustment forrisk factors, the risk of death from cancer among the men whowalked the least was 2.4 times that among those who walked themost (P = 0.03).
Discussion
In this study we investigated the effects of low-intensity activity(walking) on overall mortality in a cohort of nonsmoking, physicallycapable older men who participated in the Honolulu Heart Program.Our results suggest that walking is associated with a lowerrisk of death among such men.
Although the relative risks appear to be small, the effectsof walking on the absolute differences in mortality are actuallylarge. After 12 years of follow-up, 43.1 percent of the menwho walked less than one mile per day had died, as comparedwith 21.5 percent of the men who walked more than two milesper day. To quantify further the effect of walking on mortality,we modeled the distance walked as a continuous variable; theresults suggest that the risk of death can be reduced by 19percent when the distance walked is increased by one mile perday.
In this study we specifically examined the relation betweenthe low-intensity activity of walking and the risk of deathamong nonsmoking, retired, physically capable men. The purposeof limiting the follow-up to retired men was to reduce potentialbias due to the inclusion of men who continued to work awayfrom home and to focus specifically on activity during retirement.Excluding men who were physically incapable of participatingin low-intensity activities on a daily basis also allowed usto focus on men for whom changes in physical activity wouldbe possible. Our inclusion of only men who were physically capablemakes it less likely that the levels of activity observed inthe Honolulu Heart Program were related to mortality throughassociations with disability and physical impairment. Even amongthe men who reported walking at least a half-mile a day, thedistance walked continued to be inversely associated with mortalityafter adjustment for age and the other risk factors (P = 0.04).
The distance walked also appeared to have a beneficial effecton mortality among the men who were excluded from follow-up.In this group, most were still working (455), and a large proportionsmoked cigarettes (259). Because of the potential influenceof diverse work environments and the confounding effects ofcigarette smoking,12,13,14,15 however, the benefits of walkingin this sample are harder to evaluate. Although walking wasinversely related to total mortality and possibly to death fromcancer, associations were weaker than in the sample of men whowere retired nonsmokers.
Unfortunately, observational studies often have a limited abilityto describe relations between physical activity and the riskof disease because of difficulties in quantifying highly variablebehavioral patterns on the basis of self-reported informationand individual recall. Selection bias may also exist among oldermembers of the Honolulu cohort, since morbidity and mortalitymay have removed men who were perhaps less fit, leaving a groupof healthy survivors who were more robust.
Documenting the consistency of behavioral patterns over timeis also difficult, particularly in those who die before theirbehavior can be reassessed. Of the original sample of 707 nonsmokingand retired men, however, 422 were reexamined 10 years later(1991 to 1993). Among those who walked the most at the timeof the base-line examination (>2 miles per day), 29 percent(34 of 119) continued to do so after 10 years, and 60 percent(71 of 119) continued to walk a mile or more per day. Amongthose who walked the least at base line (<1 mile per day),74 percent (53 of 72) continued to walk less than a mile perday 10 years later. Although levels of activity may be expectedto decline as age increases in the more active men, such datasuggest that daily walking over a period of 10 years was notuncommon and may be a factor in reducing the risk of early mortalityamong older men.
Information on specific forms of activity other than walkingin the Honolulu Heart Program is also limited. In our sample,only 29 men reported that they jogged. Although data were availableon the numbers of flights of stairs climbed, there was no associationbetween climbing stairs and the distance walked or mortality.The numbers of flights of stairs climbed could have little meaninghere, since the value of such information might be influencedby the number of stories in a home as well as by physical ability.
Information about the intensity of walking by the men in thisstudy also was not available. Presumably, however, the intensitywas less variable and possibly lower in this group of men thanit might be in groups that are more heterogeneous. Walking inHawaii may also be more easily sustained and uniformly practicedthroughout the year because of the mild climate. Concomitanthigh-intensity activity is probably not a confounding factor,since only a few men reported undertaking any heavy activity(45 of 707). After these men were excluded, the associationsbetween walking and mortality remained significant.
Since walking appears to have a positive effect in reducingthe risk of death from cancer and cardiovascular disease inaddition to its effect on overall mortality, the explanatorymechanisms are probably multifactorial. Presumably, walkingreduces the risk of death from coronary heart disease and strokethrough mechanisms related to cardiovascular fitness, includingeffects on hypertension, lipid profiles, and clotting mechanisms.Although such an association would be difficult to observe,the levels of walking in this study may have been associatedwith healthier lifestyles that were adhered to throughout life.Although the effects of walking on mortality were independentof other risk factors, the men who walked the least may havebeen more prone to changes over time in risk factors that affectprogression to cardiovascular disease (e.g., the developmentof hypertension) than those who walked greater distances.
In addition to the Honolulu Heart Program, other studies havealso focused on the benefits of physical activity in older menand women, particularly in the light of the projected increasesin the elderly population into the early part of the next century.1,2,3,4,5,6Of the studies published, however, few controlled for confoundingrisk factors that are relevant to older retired men, includingphysical capabilities and the use of alcohol and tobacco. Otherstudies tended to define activity more broadly or to focus lessnarrowly on older retired men who were physically capable thanour study did. Only the Harvard Alumni Study has addressed theeffects of walking on mortality rates.3 The results of thatstudy indicated that men 35 to 74 years of age who walked 1.3miles (2.1 km) or more per day had a 22 percent lower risk ofdeath than men who walked less than 0.3 mile (0.5 km) per day.The Harvard investigators, however, did not limit their studyto retired nonsmoking men who were physically capable of low-intensityactivity.
Of course, the effects on longevity of intentional efforts toincrease the distance walked per day by physically capable oldermen cannot be addressed in our study. Our findings do, however,provide some evidence that mortality is reduced when the distancewalked is increased. In the light of previous evidence thatactive lifestyles reduce the risk of cardiovascular diseaseand other adverse outcomes in younger and more diverse groupsof people, increasing the amount of low-intensity activity islikely to benefit the health of the elderly as well. In addition,compliance with recommendations to increase the time spent insimple activities such as walking, which require only modestamounts of effort, may be easier to achieve than compliancewith recommendations of more vigorous exercise.
Supported by a contract (NO1-HC-05102) with the National Heart,Lung, and Blood Institute and by a Research Centers in MinorityInstitutions Award (P20 RR/AI 11091) from the National Institutesof Health.
Source Information
From the Division of Biostatistics, University of Virginia School of Medicine, Charlottesville (A.A.H., R.D.A.); the University of Minnesota Medical School, Minneapolis (A.A.H.); and the Department of Medicine, John A. Burns School of Medicine, University of Hawaii (H.P., C.M.B., G.W.R., B.L.R., J.D.C., R.D.A.); the Honolulu Heart Program, Kuakini Medical Center (H.P., B.L.R., K.Y., J.D.C., R.D.A.); the Honolulu Epidemiology Research Section, Epidemiology and Biometry Program, National Heart, Lung, and Blood Institute (C.M.B.); the Department of Veterans Affairs (G.W.R.); and the National Institute on Aging (L.R.W.) — all in Honolulu.
Address reprint requests to Dr. Abbott at the Division of Biostatistics, Box 600, University of Virginia School of Medicine, Charlottesville, VA 22908.
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