A Prospective Study of Walking as Compared with Vigorous Exercise in the Prevention of Coronary Heart Disease in Women
JoAnn E. Manson, M.D., Dr.P.H., Frank B. Hu, M.D., Ph.D., Janet W. Rich-Edwards, Sc.D., Graham A. Colditz, M.D., Dr.P.H., Meir J. Stampfer, M.D., Dr.P.H., Walter C. Willett, M.D., Dr.P.H., Frank E. Speizer, M.D., and Charles H. Hennekens, M.D., Dr.P.H.
Background The role of walking, as compared with vigorous exercise,in the prevention of coronary heart disease remains controversial,and data for women on this topic are sparse.
Methods We prospectively examined the associations between thescore for total physical activity, walking, and vigorous exerciseand the incidence of coronary events among 72,488 female nurseswho were 40 to 65 years old in 1986. Participants were freeof diagnosed cardiovascular disease or cancer at the time ofentry and completed serial detailed questionnaires about physicalactivity. During eight years of follow-up, we documented 645incident coronary events (nonfatal myocardial infarction ordeath from coronary disease).
Results There was a strong, graded inverse association betweenphysical activity and the risk of coronary events. As comparedwith women in the lowest quintile group for energy expenditure(expressed as the metabolic-equivalent [MET] score), women inincreasing quintile groups had age-adjusted relative risks of0.77, 0.65, 0.54, and 0.46 for coronary events (P for trend<0.001). In multivariate analyses, the inverse gradient remainedstrong (relative risks, 0.88, 0.81, 0.74, and 0.66 for womenin increasing quintile groups as compared with those in thelowest quintile group; P for trend=0.002). Walking was inverselyassociated with the risk of coronary events; women in the highestquintile group for walking, who walked the equivalent of threeor more hours per week at a brisk pace, had a multivariate relativerisk of 0.65 (95 percent confidence interval, 0.47 to 0.91)as compared with women who walked infrequently. Regular vigorousexercise (6 MET) was associated with similar risk reductions(30 to 40 percent). Sedentary women who became active in middleadulthood or later had a lower risk of coronary events thantheir counterparts who remained sedentary.
Conclusions These prospective data indicate that brisk walkingand vigorous exercise are associated with substantial and similarreductions in the incidence of coronary events among women.
In epidemiologic studies, physical activity has been associatedwith a decrease in the risk of coronary heart disease,1,2 butdata on women have been sparse. Moreover, the specific roleof walking, the most common form of exercise among women,3 hasnot been fully elucidated. The most recent federal guidelinesfrom the Centers for Disease Control and Prevention and theAmerican College of Sports Medicine,4 as well as the SurgeonGeneral's report on physical activity and health,3 endorse atleast 30 minutes of moderate-intensity physical activity onmost, and preferably all, days of the week, whereas earlierguidelines recommended vigorous endurance exercise for at least20 minutes three or more times per week.5 Although the currentguidelines encourage a level of activity that is safe, achievable,and feasible for most Americans (60 percent of whom do not engagein regular physical activity),6,7 the potential benefits ofmoderate-intensity activity in preventing coronary heart diseaseremain unclear.
We therefore assessed the comparative roles of walking and vigorousexercise in the prevention of coronary events in a large cohortof women enrolled in the prospective Nurses' Health Study. Detailedand repeated assessments of physical activity were performedto examine the degree to which total physical activity, walkingtime and pace, vigorous exercise, and change in activity levelwere associated with the incidence of coronary events in thiscohort.
Methods
Study Population
The Nurses' Health Study was initiated in 1976, when 121,700female registered nurses 30 to 55 years old who were residingin 11 large U.S. states completed a mailed questionnaire ontheir medical history and lifestyle. Every two years, follow-upquestionnaires have been sent to obtain updated informationon potential risk factors and to identify newly diagnosed casesof coronary heart disease or other illnesses. For the primaryanalyses in the present study, the base-line data were thosegathered in 1986, when detailed information on physical activitywas first collected, and the duration of follow-up was eightyears. After women who reported a diagnosis of cardiovasculardisease or cancer at base line were excluded, the populationfor analysis was made up of 72,488 women 40 to 65 years oldin 1986.
Assessment of Physical Activity
Detailed information on physical activity was first collectedin 1986 and was updated in 1988 and 1992. Participants wereasked to report the average amount of time spent per week duringthe previous year in walking or hiking outdoors (including walkingto work or while playing golf), jogging (at a speed slower than10 minutes per mile [6 minutes per kilometer]), running (at10 minutes per mile or faster), bicycling (including the useof a stationary bicycle), swimming laps, playing tennis or squash,or participating in calisthenics, aerobics, or aerobic dance;in addition, the women were asked to report the average numberof flights of stairs they climbed each week. Women also reportedtheir usual walking pace: easy or casual (<2.0 miles perhour [mph] [3.2 km per hour]), average (2.0 to 2.9 mph [3.2to 4.6 km per hour]), brisk (3.0 to 3.9 mph [4.8 to 6.2 km perhour]), or very brisk (4.0 mph [6.4 km per hour]). Using a standardizedclassification of the energy costs of physical activities,8we calculated a weekly metabolic-equivalent (MET) score fortotal physical activity, vigorous activity (6 MET per hour),nonvigorous activity (<6 MET per hour), and walking (2.5to 4.5 MET per hour, depending on the pace). One MET is thecaloric need per kilogram of body weight per hour of activity,divided by the caloric need per kilogram per hour at rest. Physical-activityscores were expressed as MET-hours per week. Validation of thequestionnaire for assessing physical activity has been describedpreviously in a similar cohort9; the overall correlation betweenphysical activities reported on the questionnaire and thoserecorded in four one-week diaries was 0.62, and the correlationwas 0.79 for activities reported on the questionnaire and thoserecalled after one week.9
For secondary analyses, we used data from a shorter questionnaireabout physical activity that was administered in 1980 and 1982.On the 1980 questionnaire, women were asked to report the averagenumber of hours they spent each week during the previous yearengaged in moderate or vigorous recreational activities, includingvigorous sports, jogging, bicycling, brisk walking, heavy gardening,or heavy housework. On the 1982 questionnaire, women were askedthe question: "For how many hours per week, on average, do youengage in activity strenuous enough to build up a sweat?" Toanalyze this information, we calculated the cumulative averagenumber of hours per week spent in moderate or vigorous recreationalactivities (all the activities listed above except for walkingat a casual or average pace), as assessed in 1980, and (withupdated information) in 1982, 1986, 1988, and 1992.
Ascertainment of End Points
The primary end points for this study were coronary events (definedas nonfatal myocardial infarction or death due to coronary disease)that occurred after the return of the 1986 questionnaire andbefore June 1994. We requested permission to review the medicalrecords of women who reported a nonfatal myocardial infarctionon a follow-up questionnaire. Study physicians who had no knowledgeof the women's self-reported risk factors reviewed the records.Nonfatal myocardial infarction was confirmed if data in themedical records met World Health Organization criteria for thiscondition — namely, symptoms and either diagnostic electrocardiographicchanges or elevated cardiac-enzyme levels.10 Myocardial infarctionsthat required hospital admission and for which confirmatoryinformation was obtained by interview or letter but for whichno medical records were available were designated as probableinfarctions (and constituted 17 percent of all reported nonfatalinfarctions). We included all confirmed and probable cases ofinfarction in the analyses because the results were the samewhether probable cases were included or excluded. Follow-upinformation for nonfatal infarction was obtained for more than95 percent of the potential person-time of follow-up.
Deaths were reported by family members or the Postal Serviceor were ascertained through state registries or the NationalDeath Index. We estimate that follow-up for deaths was morethan 98 percent complete.11 Fatal coronary disease (codes 410through 414 of the International Classification of Diseases, 8th Revision12) was confirmed by review of the hospital ormedical autopsy records or by review of the death certificateif coronary disease was the stated cause of death and evidenceof previous coronary disease was available. We designated deathsfor which coronary disease was listed as the underlying causeon the death certificate, but for which no records were available,as due to presumed fatal coronary disease. These cases constituted14.7 percent of all fatal coronary events. We also includedsudden deaths (12.3 percent of all fatal coronary events). Analyseslimited to confirmed cases yielded results similar to thosein which confirmed and presumed cases of fatal coronary diseasewere combined.
Statistical Analysis
For primary analyses, we used the detailed assessment of physicalactivity performed in 1986 as the base line. Person-time foreach participant was calculated from the date of her returnof the 1986 questionnaire to the date of an incident coronaryevent, death from any cause, or June 1, 1994, whichever camefirst. Data on women who had a coronary event or who died fromany cause were censored with respect to subsequent analysisduring follow-up. The relative risk of a coronary event wascomputed as the incidence of the event in each quintile groupfor MET score, divided by the incidence in the lowest quintilegroup, with adjustment for five-year age categories. Tests oflinear trend for increasing quintiles of MET scores were performedby treating the score as a continuous variable and designatingthe median score for the category as its value. To representlong-term levels of physical activity for individual women asaccurately as possible and to reduce measurement error, we calculatedcumulative averages of the MET scores from all the questionnairesavailable up to the start of each two-year follow-up interval.A similar method for analyzing repeated dietary measurementshas been described in detail elsewhere.13
For secondary analyses, we used data gathered in 1980 as thebase line. We used the continuous values of hours of activityper week to compute the cumulative averages at the start ofeach interval and grouped the average hours per week of moderateor vigorous exercise into five categories (<1, 1 to 1.9,2 to 3.9, 4 to 6.9, and 7 hours per week). To examine the associationbetween a change in physical activity and the risk of coronaryevents, we related the change between 1980 and 1986 in hoursspent engaged in moderate or vigorous activity to coronary eventsoccurring between 1986 and 1994.
We used pooled logistic regression14 to adjust simultaneouslyfor potential confounding variables, including age (in five-yearcategories), period during the study (four two-year periods),smoking status (never smoked, previously smoked, or currentlysmokes 1 to 14, 15 to 24, or 25 cigarettes per day), body-massindex (the weight in kilograms divided by the square of theheight in meters, in five categories), alcohol consumption (0,1 to 4, 5 to 14, or 15 g per day), menopausal status (premenopausal,postmenopausal without hormone-replacement therapy, postmenopausalwith previous hormone-replacement therapy, or postmenopausalwith current hormone-replacement therapy), history of diabetes,history of hypercholesterolemia, history of hypertension, parentalhistory of myocardial infarction before the age of 60 years,use of multivitamin supplements, use of vitamin E supplements,and use of aspirin (none, one to six doses per week, or sevenor more doses per week). Covariates were updated according toquestionnaire information every two years. The population attributablerisk was calculated from multivariate models with use of thefollowing formula: ([1 – relative risk] ÷ relativerisk) x (pro-portion of inactive cases) (x100).15
Results
The distribution at base line of several indicators of coronaryrisk varied according to quintile group for total physical-activityscore (expressed as MET-hours per week) in this cohort (Table 1).Women who were more physically active were less likely tobe current smokers and, as expected, were leaner and had a lowerprevalence of reported hypertension, diabetes, and hypercholesterolemiathan less active women. More physically active women were alsomore likely to use postmenopausal hormone-replacement therapy,multivitamin and vitamin E supplements, and alcohol. In contrast,the activity level was not appreciably related to age, parentalhistory of myocardial infarction, or dietary intake of fatsor cholesterol.
Table 1. Distribution of Indicators of Coronary Risk According to Quintile Group for Total Physical-Activity Score at Base Line (1986).
The eight years of follow-up, from 1986 to 1994, included 559,435person-years. During this follow-up period we documented 645coronary events (475 nonfatal myocardial infarctions and 170deaths from coronary disease) among the 72,488 women who in1986 were 40 to 65 years old, had neither cardiovascular diseasenor cancer, and completed a detailed physical-activity questionnaire.The total physical-activity score (expressed as MET-hours perweek) in 1986 was strongly inversely related to the risk ofcoronary events during the eight-year follow-up (Table 2). Inage-adjusted analyses from 1986 to 1994 (in which MET scores,first computed in 1986, were calculated as cumulative updatedaverages in 1988 and 1992), the risk of coronary events decreasedmonotonically with increasing quintiles for MET score (relativerisks, 0.77, 0.65, 0.54, and 0.46 as compared with the riskin the lowest quintile group; P for trend <0.001). In multivariateanalyses, after simultaneous control for age, smoking status,body-mass index, and other covariates (Table 2), the total physical-activityscore remained a powerful predictor of the subsequent risk ofcoronary events; relative risks for increasing quintile groupsfor physical activity, as compared with the lowest quintilegroup, were 0.88, 0.81, 0.74, and 0.66 (P for trend=0.002).There was a significant risk reduction for the two highest quintilegroups, with a total of 10.5 MET-hours per week or more (theequivalent of 3 hours per week of brisk walking or 1.5 hoursper week of vigorous exercise). In a separate analysis in whichdata from the first two years of follow-up after completionof the activity questionnaires were excluded (to minimize potentialbias due to the influence of subclinical disease on activitylevel), the results were not materially altered (Table 2). Exclusionof biologic variables that may have a role in mediating theeffect of activity (e.g., body-mass index) strengthened theinverse association between physical-activity level and riskof a coronary event (relative risk, 0.60 [95 percent confidenceinterval, 0.46 to 0.77] for the highest vs. the lowest quintilegroup for total physical-activity score) (Table 2).
Table 2. Relative Risk of Coronary Events According to Quintile Group for Total Physical-Activity Score.
To assess the potential modifying effects of cigarette-smokingstatus, body-mass index, and parental history with respect topremature myocardial infarction on the relation between physicalactivity and coronary events, analyses were repeated withinsubgroups defined by these variables (Figure 1). Physical activitywas inversely related to the risk of coronary events in allstrata for smoking (never, previously, and currently), for bothnonobese and obese women, and for women with and those withouta parental history of premature myocardial infarction.
Figure 1. Multivariate Relative Risk of Coronary Events (Nonfatal Myocardial Infarction or Death from Coronary Causes) According to Quintile Group for Total Physical Activity within Subgroups Defined According to Smoking Status (Panel A), Body-Mass Index (Panel B), and Presence or Absence of a Parental History of Premature Myocardial Infarction (Panel C).
For each risk factor, the reference group is the category at highest risk. Relative risks have been adjusted for the variables in the full multivariate model (listed in Table 2).
We next used the 1980 questionnaire to assess the long-termassociation between moderate and vigorous recreational activity(from data updated in 1982, 1986, 1988, and 1992) and the incidenceof coronary events from 1980 to 1994. The activities includedwere vigorous sports, jogging, bicycling, brisk walking, heavygardening, heavy housework, and activities "strenuous enoughto build up a sweat." The number of hours per week of moderateor vigorous activity were strongly inversely related to therisk of coronary events. In multivariate analyses, averagesof 4.0 to 6.9 and 7 or more hours per week spent in these activitieswere associated with risk reductions of 31 percent and 37 percent,respectively, as compared with an average of less than 1 hourper week (P for trend <0.001).
To assess the role of changes in activity level during the follow-upperiod, we categorized information from women according to theiractivity in 1980 relative to that in 1986. In an analysis restrictedto women who were sedentary (exercised less than once per week)in 1980 (54 percent of the cohort at that time), women who remainedsedentary in 1986 had substantially higher rates of coronaryevents than women who became active. As compared with the riskamong women who remained sedentary, the multivariate risks ofcoronary events from 1986 to 1994 for women in increasing quintilegroups for total physical activity (MET score) in 1986 were0.85, 0.79, 0.67, and 0.71 (P for trend=0.03).
Detailed information about walking (duration and pace) was firstobtained in 1986 and was updated in 1988 and 1992. Approximately60 percent of the cohort of 72,488 women reported in 1986 thatthey walked for at least one hour per week, whereas only 26percent engaged in vigorous exercise (6 MET) for at least onehour per week. To address the association between walking andthe risk of coronary events while minimizing the potential confoundingeffect of vigorous activity, we restricted the study populationto the women who reported no vigorous exercise (47 percent ofthe cohort). Women in the two highest quintile groups for walkingscore (a composite of walking time and pace) had a significantlyreduced risk of coronary events as compared with the risk inthe lowest quintile group (Table 3). As compared with sedentarywomen, women who had a walking score of 3.9 to 9.9 MET-hoursper week — the equivalent of 1 to 2.9 hours of walkingper week at a brisk pace 3 mph — had a multivariate relativerisk of 0.70 (95 percent confidence interval, 0.51 to 0.95)for subsequent coronary events, and those with scores of 10or more MET-hours per week — the equivalent of 3 or morehours of walking per week at a brisk pace — had a multivariaterelative risk of 0.65 (95 percent confidence interval, 0.47to 0.91) for subsequent coronary events (P for trend=0.02).For those who walked five or more hours per week, the risk reductionexceeded 40 percent (data not shown). Exclusion of the smallnumber of women who reported that they were "unable to walk"on the 1990 or 1992 questionnaire (2 percent of the cohort)did not alter these results.
Table 3. Relative Risk of Coronary Events among Women Who Did Not Engage in Vigorous Exercise, According to Quintile Group for Walking.
Walking pace was also an important determinant of the risk ofcoronary events (Figure 2). In multivariate analyses that alsoincluded control for time spent walking (in MET-hours per week),walking pace emerged as an independent predictor of the riskof coronary events. As compared with women who walked at aneasy or casual pace (<2.0 mph), women who usually walkedat an average pace (2.0 to 2.9 mph) had a multivariate relativerisk of 0.75 (95 percent confidence interval, 0.59 to 0.96),whereas those who walked briskly or very briskly (3.0 mph) hada relative risk of 0.64 (95 percent confidence interval, 0.47to 0.88).
Figure 2. Age-Adjusted and Multivariate Relative Risks of Coronary Events (Nonfatal Myocardial Infarction or Death from Coronary Causes) According to Walking Pace.
These analyses excluded women who engaged in vigorous exercise. Multivariate relative risks have been adjusted for the variables in the full multivariate model, as listed in Tables 2 and 3, and for MET score for walking. Women who walked at an easy or casual pace served as the reference group. I bars indicate 95 percent confidence intervals. To convert miles per hour to kilometers per hour, multiply by 1.6.
To assess the comparative roles of walking and vigorous exercisein relation to coronary risk, we examined the incidence of coronaryevents according to the joint distribution of MET-hours perweek spent in these activities (Table 4). Women who engagedin both walking and vigorous exercise had greater reductionsin coronary events than those who participated in either typeof activity alone. When examined simultaneously in a multivariatemodel, walking and vigorous exercise were each associated witha risk reduction. For every 5 MET-hours per week spent walking(the equivalent of 1.5 hours of walking per week at a briskpace), the multivariate relative risk of coronary events was0.86 (95 percent confidence interval, 0.74 to 0.99; ßcoefficient, –0.157), and for every 5 MET-hours per weekspent in vigorous exercise (the equivalent of jogging, bicycling,swimming laps, or playing tennis for 45 minutes per week), themultivariate risk was 0.94 (95 percent confidence interval,0.89 to 0.99; ß coefficient, –0.059). Thus,we did not observe a greater magnitude of risk reduction withvigorous exercise than with walking in this cohort when we comparedthose who walked with those who exercised vigorously a similarnumber of MET-hours per week. However, our ability to assessthe role of vigorous exercise was limited because of the smallnumber of women in this study population (26 percent of thecohort) who engaged regularly in vigorous exercise.
Table 4. Multivariate Relative Risks of Coronary Events According to Categories of Vigorous Exercise and Walking.
Discussion
These prospective data from a large cohort of women indicatethat both walking and vigorous exercise are associated withsubstantial reductions in the incidence of coronary events.We observed that in this cohort, the magnitudes of risk reductionassociated with brisk walking and vigorous exercise were similarwhen total energy expenditures were similar. These findingslend further support to current federal exercise guidelines,which endorse moderate-intensity exercise for at least 30 minuteson most (preferably all) days of the week.3,4 Our results suggestthat such a regimen (e.g., brisk walking for three or more hoursper week) could reduce the risk of coronary events in womenby 30 to 40 percent. Increasing walking time or combining walkingwith vigorous exercise appears to be associated with even greaterrisk reductions. Given the high prevalence in the United Statesof a sedentary lifestyle (78 percent of adults engage in lessphysical activity than currently recommended),3 we estimate,on the basis of our multivariate relative-risk analyses, thatone third of coronary events among middle-aged women in theUnited States are attributable to physical inactivity.
The strengths of the current study include the prospective design,the large size of the cohort, the long-term follow-up, repeatedmeasures of physical activity, and the uniform and strict criteriafor coronary events. Women with diagnosed cardiovascular diseaseor cancer at base line were excluded from the analyses. Theseexclusions and the prospective design minimized any influencethat underlying disease may have had on physical-activity levelsand decreased the potential for biased reporting of activity.Moreover, in our secondary analyses, the first two years offollow-up were excluded in order to minimize bias related tosubclinical disease. The repeated measures of physical activityenabled us to calculate more stable, cumulative, and updatedclassifications of activity status as well as to assess therole of changes in activity level over time. Other advantagesinclude the level of detail of information gathered about walkingtime and pace on the survey first administered in 1986, thehigh rate of participation during follow-up, and the collectionof information about a large number of potential confounders,including cigarette smoking, body-mass index, family historyof myocardial infarction, postmenopausal hormone use, alcoholconsumption, diet, and other coronary risk factors. The substantialreduction in the risk of coronary events among women who increasedtheir activity level, as compared with women who remained sedentary,and the strong dose–response gradient observed in eachanalysis lend credence to the interpretation that there is acausal relation between physical activity and a reduced riskof coronary events and that the risk may be modified throughincreased activity, even when it is begun in later adulthood.
Because our multivariate analyses controlled for several factorsthat could be considered intermediate biologic variables (suchas body-mass index and a history of hypertension, hypercholesterolemia,or diabetes),3 the analyses provide a conservative estimateof the relation between physical activity and coronary disease.In analyses that excluded these biologic intermediates, theinverse association between physical activity and coronary eventswas strengthened (Table 2).
Limitations of the current study must also be considered. Physicalactivity was assessed by a self-administered questionnaire and,despite the use of repeated measures, there was undoubtedlysome misclassification. However, in a validation study, conductedin a separate cohort of nurses, the correlations between physicalactivity as reported on the questionnaire and as recorded infour one-week diaries or recalled after one week were reasonablyhigh (r=0.62 and r=0.79, respectively).9 Random misclassificationswould be expected to lead to underestimation of the true associationand to bias the estimate of risk toward unity; therefore, misclassificationcannot explain the strong inverse associations in our cohortbetween physical-activity level and the incidence of coronaryevents. Nevertheless, despite the control for many potentialconfounding variables in our multivariate analyses, residualconfounding by lifestyle factors cannot be excluded. In thisregard, it should be noted (Table 1) that the more active womenhad more favorable risk profiles. Finally, our study population,consisting of registered nurses, is not representative of thegeneral population. The relative homogeneity of the cohort ineducational attainment and socioeconomic status may actuallyserve to enhance the internal validity of this study; confoundingby these factors has posed an important problem in many previousstudies of physical activity and coronary disease.
More than 40 epidemiologic studies have addressed the relationbetween exercise and coronary disease,1,2 but few have includedwomen and presented data on women separately.16,17,18,19,20,21,22,23,24In those that did, results in women were generally similar tothose in men, indicating that risk reductions were 30 to 50percent in both sexes with regular physical activity. Most ofthese studies were small, however, and did not collect detailedinformation about walking or report repeated measures of activity.The evidence that moderate-intensity activity is associatedwith a reduction in the risk of coronary disease, however, hasbeen mounting. In a recent report from the Iowa Women's HealthStudy, both moderate activity and vigorous activity were inverselyrelated to overall mortality and mortality due to cardiovascularcauses,20 although walking was not assessed separately. In tworecent studies among elderly women24 and men,25 walking at leastfour hours per week was associated with substantial reductionsin cardiovascular risk.
Even moderate levels of physical fitness (assessed by treadmilltesting) have been associated with substantial reductions inmortality due to cardiovascular events and in total mortality.23It is unlikely that genetic and constitutional differences infitness levels and in the ability to exercise explain thesefindings: in a study of nearly 16,000 men and women in the FinnishTwin Cohort, leisure-time physical activity was associated withreduced mortality, even after the analyses had accounted forgenetic, familial, and behavioral factors.26
It is also biologically plausible that both moderate exerciseand vigorous exercise have an important role in reducing coronaryrisk. Increasing the intensity or duration of exercise has agraded relation to improvements in lipid concentrations3,27and insulin sensitivity.28 Randomized trials of the effectsof different intensities of exercise on blood pressure suggestthat moderate- and vigorous-intensity activity may confer similarreductions in diastolic blood pressure and that moderate-intensityactivity may confer even greater reductions in systolic bloodpressure than vigorous-intensity exercise.3 In the Insulin ResistanceAtherosclerosis Study, both vigorous and nonvigorous levelsof physical activity were directly associated with insulin sensitivity.28Moreover, equivalent expenditures of energy in moderate or vigorousexercise will lead to similar reductions in adipose mass.3 Arecent study indicated that moderate-intensity exercise reducesthe secretion of atherogenic cytokines.29 Finally, physicalactivity of all intensities has been linked to improvement inemotional well-being and reduction in anxiety and stress.3
In conclusion, these prospective data from a study of a largecohort of women indicate that both walking and vigorous exerciseare associated with substantial reductions in the risk of coronaryevents. We observed a strong, graded inverse relation betweenenergy expenditure in either walking or vigorous activity andthe incidence of coronary disease. Among women who either walkedbriskly at least 3 hours per week or exercised vigorously for1.5 hours per week, the risk was reduced by 30 to 40 percent.These findings lend support to current federal guidelines thatendorse moderate-intensity exercise, which is safe, achievable,and feasible for the majority of the population. Although vigorousexercise should not be discouraged for those who choose a higherintensity of activity, our results indicate that enormous publichealth benefits would accrue from the adoption of regular moderate-intensityexercise by those who are currently sedentary.
Supported by research grants (HL34594 and CA40356) from theNational Institutes of Health.
We are indebted to the participants in the Nurses' Health Studyfor their outstanding dedication and commitment; and to KarenCorsano, Gary Chase, Barbara Egan, Lisa Dunn, Sandra Melanson,Jeanne Grol, and Stefanie Parker for their unfailing assistance.
Source Information
From the Channing Laboratory (J.E.M., G.A.C., M.J.S., W.C.W., F.E.S.) and the Division of Preventive Medicine (J.E.M., C.H.H.), Department of Medicine, Harvard Medical School and Brigham and Women's Hospital; the Departments of Nutrition (F.B.H., M.J.S., W.C.W.) and Epidemiology (J.E.M., G.A.C., M.J.S., W.C.W., C.H.H.), Harvard School of Public Health; and the Department of Ambulatory Care and Prevention, Harvard Medical School (J.W.R.-E., C.H.H.) — all in Boston.
Address reprint requests to Dr. Manson at Brigham and Women's Hospital, 181 Longwood Ave., Boston, MA 02115, or at jmanson{at}rics.bwh.harvard.edu.
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