1iztjdbm bdujwjuz boe ifbmui jo nje bhf boe pmefs
TRANSCRIPT
September
PHYSICAL ACTIVITY AND HEALTHIN MID-AGE AND OLDER WOMEN
Wendy J Brown, PhD
Nicola W Burton, PhD
Kristiann C Heesch, DrPH
School of Human Movement Studies
The University of Queensland
A report for The Office for Women
Department of Families, Community Services and Indigenous Affairs
September 2007
Suggested Citation
Brown WJ, Burton NW, Heesch KC. (2007). Physical activity and health in mid age and older women. Canberra: The Office for Women, Department of Families, Community Services, and Indigenous Affairs.
ISBN 978-1-921380-77-8
Acknowledgements
The findings presented in parts three and four of this report are based on data from the Australian
Longitudinal Study on Women's Health (www.alswh.org.au). Support for this research (literature
review, analyses, writing) was provided by the Office for Women, Australian Government
Department of Families, Community Services and Indigenous Affairs.
The cartoons in this report were done by Jenny Coopes for the report Selected findings from
juggling time: How Australian families use time, which was produced by the Office for the Status
for Women, Department of the Prime Minister and Cabinet, 1991
The contributions of the following people to the analyses and writing in sections of this
report are gratefully acknowledged (in alphabetical order)
Dr Julie Byles, PhD
Ms Gretchen A Carrigan, BSc(Statistics), BEcon
Professor Annette Dobson, PhD
Mr Richard Hockey, BSc
Dr Yvette Miller, PhD
Ms Siobhan O'Dwyer, BSc(Hons)
Dr Mireille van Poppel, PhD
PHYSICAL ACTIVITY AND HEALTH IN MID-AGE AND OLDER WOMEN
Purpose of Report
This report examines the links between physical activity and
health in mid-age and older women.
� PART ONE: an update of the evidence relating physical
activity to the national public health priorities in women.
� PART TWO: consideration of the amount of physical activity
necessary for good health in mid-age and older women.
� PART THREE: new data on activity patterns among mid-age
and older participants in the Australian Longitudinal Study on
Women's Health. This section includes new data on
relationships between life events and changes in physical
activity, and the associations between sociodemographic
characteristics and health behaviour variables with changes
in physical activity over time.
� PART FOUR: new data on the relationships between
physical activity and selected health outcomes in mid-age
and older women.
Queries Professor Wendy Brown
School of Human Movement Studies
The University of Queensland, St Lucia QLD 4072
Tel: 07 3365 6446 Fax: 07 3365 6877
Email: [email protected]
SecondaryContact
Dr Nicola Burton
School of Human Movement Studies
The University of Queensland, St Lucia QLD 4072
Tel: 07 3365 6282 Fax: 07 3365 6877
Email: [email protected]
i
TABLE OF CONTENTS
EXECUTIVE SUMMARY xi
1 PHYSICAL ACTIVITY AND HEALTH – UPDATING THE EVIDENCE FOR WOMEN
1.1 Introduction 1
A focus on primary prevention 2
1.2 Methods 4
Interpreting the data – the importance of the physical activity measure 4
Other methodological considerations 7
1.3 Cardiovascular Disease 8
1.4 Type 2 Diabetes 14
A note about the secondary prevention trials for diabetes 18
Gestational diabetes 19
1.5 Cancer 20
Breast cancer 21
Colon cancer 26
Other cancers 27
1.6 Mental Health 29
Cognitive functioning 31
A note about secondary and tertiary management of mental health problems 33
1.7 Musculoskeletal Problems 34
Osteoarthritis 34
1.8 Injury 37
1.9 Reproductive Health 40
1.10 Discussion 42
ii
2 HOW MUCH ACTIVITY FOR HEALTH BENEFITS IN WOMEN?
2.1 Introduction 45
2.2 Intensity 47
2.3 Duration 49
2.4 Frequency 50
2.5 Total Time and Volume of Activity: Duration, Frequency and Intensity 51
2.6 Discussion 52
3 HOW ACTIVE ARE AUSTRALIAN MID-AGE AND OLDER WOMEN?
3.1 Introduction 55
3.2 The Australian Longitudinal Study on Women's Health 56
Features of the ALSWH study design 57
What is included in the surveys 57
Response rates 59
Area of residence 60
Measurement of physical activity 60
3.3 Prevalence and Patterns of Physical Activity 61
Patterns of physical activity 64
Physical activity and paid and unpaid work 65
3.4 Trends in Physical Activity Over Time 68
Trends in walking over time 70
Changes in physical activity categories over time 72
3.5 Factors Associated with Physical Activity Changes Over Time 75
Mid-age women 75
Older women 78
3.6 Associations Between Life Events and Changes in Physical Activity 81
Mid-age women 81
Older women 83
3.7 Discussion 85
iii
4 RELATIONSHIPS BETWEEN PHYSICAL ACTIVITY AND SELECTED HEALTH OUTCOMES IN AUSTRALIAN MID-AGE AND OLDER WOMEN.
4.1 Introduction 89
4.2 Does Physical Activity Protect Against Menopausal Symptoms in Mid-Age Women? 91
4.3 Does Physical Activity Protect Against Stiff or Painful Joints and Arthritis in Mid-Age And Older Women? 95
4.4 Does Physical Activity Protect Against Anxiety and Depression in Older Women?
98
4.5 Does Physical Activity Protect Against Memory Problems in Older Women? 101
4.6 Does Physical Activity Protect Against Falls and Fractures in Older Women? 105
4.7 Is There a Relationship Between Physical Activity and General Physical and Psychological Well-Being in Mid-Age And Older Women?
109
4.8 Is There any Relationship Between Physical Activity and Health Care Costs in Mid-Age and Older Women?
113
4.9 Discussion 117
REFERENCES 121
iv
TABLE OF APPENDICES
APPENDIX A: Population Based Studies of the Association Between Physical Activity and Coronary Heart Disease/Cardiovascular Disease 140
APPENDIX B: Population Based Studies of the Association Between Physical Activity and Diabetes 157
APPENDIX C: Population Based Studies of the Association Between Physical Activity and Gestational Diabetes 168
APPENDIX D: Population Based Studies of the Association Between Physical Activity and Breast Cancer 171
APPENDIX E: Population Based Studies of the Association Between Physical Activity and Colorectal Cancer 185
APPENDIX F: Population Based Studies of the Association Between Physical Activity and Cancer (Excluding Breast and Colorectal Cancer) 189
APPENDIX G: Population Based Studies of the Association Between Physical Activity and Mental Health 200
APPENDIX H: Population Based Studies of the Association Between Physical Activity and Musculoskeletal Health 212
APPENDIX I: Population Based Studies of the Association Between Physical Activity and Injury 215
APPENDIX J: Population Based Studies of the Association Between Physical Activity and Reproductive Health 225
v
LIST OF TABLES
Table 3.1 Estimates of physical activity from consecutive surveys of mid-age women
73
Table 3.2 Estimates of physical activity from consecutive surveys of older women
73
Table 3.3 Summary of demographic and health-related variables associated with three categories of physical activity change in the mid-age women (N=7,721)
76
Table 3.4 Summary of demographic and health-related variables associated with three categories of physical activity change in the older women (N=4,697)
79
Table 4.1 Mean (SE) MAC-Q scores for women in each physical activity category (O3 survey; N=4,289)
103
Table 4.2 Association between physical activity categories and MAC-Q score >29 in older women at O3 (N=4,298)
103
vi
LIST OF FIGURES
Figure 1.1 Relative risk of cardiovascular disease outcomes by approximate quintiles of physical activity
11
Figure 1.2 Relative risk of cardiovascular disease outcomes by approximate quintiles of walking
12
Figure 1.3 Relative risk of cardiovascular disease outcomes by walking pace 13
Figure 1.4 Relative risk of diabetes by approximate quintiles of physical activity
15
Figure 1.5 Relative risk of diabetes by approximate quintiles of walking 17
Figure 1.6 Relative risk of breast cancer by approximate quintiles of physical activity
22
Figure 1.7 Relative risk of breast cancer by approximate quintiles of vigorous-intensity physical activity
24
Figure 3.1 Timeline and ages of the women at each of the ALSWH surveys 58
Figure 3.2 Proportions of women in each physical activity category in subsequent surveys at M2 (N=11,226), M3 (N=10,671), and M4 (N=10,163); and at O2 (N=9,123), O3 (N=8,052) and O4 (N=6,523)
63
Figure 3.3 Box plots for physical activity by occupation category (M4 data; N 9241)
66
Figure 3.4 Box plots for physical activity by hours of paid work (M4 data; N=10,041)
67
Figure 3.5 Median and inter-quartile ranges for physical activity in the mid-age cohort at M3 (2001) and M4 (2004) (N=9,167) and in the older cohort at O2 (1999) and O3 (2002) (N=7,134)
69
Figure 3.6 Median and inter-quartile ranges for time spent walking in the mid-age women (at M2, M3 and M4; N=8,693) and in the older women (at O2, O3 and O4; N=5,611)
71
Figure 3.7 Changes in physical activity in the mid-age (N=9,167) and older (N=7,137) cohorts
74
Figure 4.1 Mean menopausal symptoms scores by menopause transition (M3 to M4) and physical activity categories at M3 (N=3,330)
93
vii
Figure 4.2 Odds ratios (and 95% CI) for associations between physical activity at M3/O2 and often having (a) stiff or painful joints (mid-age N=4,780; older N=3,970) and (b) arthritis (mid-age N= 7,217; older N=4,165) at M4 and O3 respectively
97
Figure 4.3 Mean (SE) GADS scores at O3 for women in each physical activity category at O2 (N=4,228)
100
Figure 4.4 Unadjusted and adjusted odds ratios for reporting a fall to the ground at O3, by O1 physical activity categories (N=6,468)
107
Figure 4.5 Unadjusted and adjusted odds ratios (and 95% confidence intervals) for reporting a broken or fractured bone at O3, by O1 physical activity categories (N=6,468)
108
Figure 4.6 Cross-sectional relationships between physical activity categories and SF36 PCS scores (left hand side) and MCS scores (right hand side) for (a) mid-age women at M1 (N=9,729) and (b) older women at O1 (N=7,984) in 1996 (mean and 95% CI)
110
Figure 4.7 Mean (and 95% CI) PCS (left hand side) and MCS (right hand side) scores for each physical activity change category in (a) the mid-age women (M3 to M4; N=8,437) and (b) the older women (O2 to O3; N=5,416)
112
Figure 4.8 Mean annual costs of Medicare rebateable health services by physical activity category for mid-age women in 2001 (pale bars; N=7,204; M3 survey) and older women in 1999 (darker bars; N= 4161; O2 survey)
115
viii
LIST OF ABBREVIATIONS
ALSWH Australian Longitudinal Study on Women's Health
ASCO Australian Standard Classification of Occupations
BMD Bone mineral density
CHD Coronary heart disease
CI Confidence interval
CVD Cardiovascular disease
GDM Gestational diabetes
HDL-C High density lipoprotein cholesterol
HR Hazard ratio
IQR Inter-quartile ranges
kJ Kilojoules (a measure of energy expenditure)
M1 First survey of mid-age women in the Australian Longitudinal Study on Women's Health (1996)
M2 Second survey of mid-age women in the Australian Longitudinal Study on Women's Health (2000)
M3 Third survey of mid-age women in the Australian Longitudinal Study on Women's Health (2003)
mins minutes
mPA Moderate intensity physical activity
NHANES National Health and Nutrition Examination Survey (USA)
NHS Nurses Health Study
NIDDM Non-insulin-dependent diabetes mellitus
O1 First survey of older women in the Australian Longitudinal Study on Women's Health (1996)
ix
O2 Second survey of older women in the Australian Longitudinal Study on Women's Health (1999)
O3 Third survey of older women in the Australian Longitudinal Study on Women's Health (2002)
O4 Fourth survey of older women in the Australian Longitudinal Study on Women's Health (2005)
OA Osteoarthritis
OR Odds ratio
RR Relative risk
SOF Study of Osteoporotic Fractures
US United States of America
USSG United States Surgeon General
vPA Vigorous intensity physical activity
WHI Women's Health Initiative
WHS Untied States Women's Health Study
x
PUBLICATIONS ASSOCIATED WITH THIS REPORT
(AS AT JULY 2007)
More detailed information on some of the analyses presented in this report can be found in
the following publications.
Brown WJ, Burton NW, & Rowan PJ. (in press). Up dating the evidence on physical activity
and health in women. Accepted by American Journal of Preventive Medicine, July 20,
2007.
Heesch KC, Byles J, Brown WJ. (in press). Prospective association between physical activity
and falls in community-dwelling older women. Accepted by Journal of Epidemiology and
Community Health, July 31, 2007.
Heesch KC, Miller YD, & Brown WJ. (2007). Relationship between physical activity and stiff
or painful joints in mid-aged and older women: A 3 year prospective study. Arthritis
Research & Therapy. 9:R34 (29 March 2007)
xi
EXECUTIVE SUMMARY
Introduction
� The US Surgeon General's report was a landmark publication in the field of physical activity and
health, but was constrained by a lack of evidence relating to women.
� This report examines the links between physical activity and health in mid-age and older women.
It includes four parts
(i) recent evidence relating physical activity to the national public health priorities and
reproductive health
(ii) consideration of the amount of physical activity required to obtain health benefits
(iii) new data from the Australian Longitudinal Study on Women's Health on activity patterns,
including relationships between changes in physical activity and life events,
sociodemographic characteristics and health behaviours in mid-age and older Australian
women
(iv) new data from the Australian Longitudinal Study on Women's Health on the relationships
between physical activity and menopausal symptoms, stiff or painful joints and arthritis,
anxiety and depression, memory problems, falls and fractures, general physical and
psychological well-being, and healthcare costs in mid-age and older Australian women
Physical Activity and Health – Updating the Evidence for Women
� A literature search was conducted to identify prospective population-based studies published from
1997 to January 2006.
� Measures of energy expenditure, derived from the frequency, intensity, and duration of physical
activity, were more consistently associated with risk reduction than other self-report physical
activity measures. Studies with comparatively large samples and a longer follow up period were
more likely to demonstrate associations between physical activity and health.
� Fourteen of seventeen studies of physical activity and indicators of cardiovascular disease (CVD)
indicated risk reductions ranging from 28 to 58%.
xii
� Seven of eight studies of physical activity and type 2 diabetes indicated risk reductions ranging
from 14 to 46%. Two studies on gestational diabetes (GDM) provided mixed evidence, with one
reporting up to 76% risk reduction, and one reporting no association.
� Ten studies of physical activity and breast cancer provided mixed results. Six studies reported
significant risk reductions with risk reductions ranging from 11 to 67%, two found non significant
trends, and two found no relationship. Three studies indicated that the association between
physical activity and breast cancer may be stronger for post-menopausal women.
� Three studies of physical activity and colon cancer were identified. One showed a significant risk
reduction of between 31 and 46%, one found no association, and one was equivocal.
� Thirteen studies of physical activity and other cancers were identified. Physical activity provided a
protective effect for bladder cancer (one study) and endometrial cancer (two studies). No
association was found between physical activity and renal cell carcinoma (one study) or lung
cancer (one study), and there were mixed results for pancreatic cancer (three studies), and all-
cancer mortality (three studies). Two studies suggested a positive relationship between physical
activity and increased risk of ovarian cancer.
� Ten studies of physical activity and mental health problems were identified. Two studies of
depression provided mixed results. Two studies of emotional well-being both found a positive
association. Five of six studies demonstrated that physical activity protects against cognitive
decline and dementia.
� Five studies of physical activity and osteoarthritis were identified, with four finding no association.
A fifth study suggested that active older people may be more at risk of osteoarthritis of the knee.
� Seven studies of physical activity and injury were identified and provided mixed evidence. Two
studies demonstrated that higher levels of physical activity provided a protective effect against hip
and vertebral fractures, with risk reductions up to 55%. Two studies found that low physical
activity levels and sedentary leisure increased the risk of fractures. There was no association
between physical activity and injury mortality (one study) or between walking and risk of second
hip fracture (one study).
� Four studies of physical activity and reproductive health (menstrual and menopausal symptoms)
were identified, and provided mixed results.
xiii
How Much Activity for Health?
� Australian guidelines recommend 30 minutes of moderate-intensity physical activity on most days
of the week for health benefits, and suggest that more vigorous physical activity will confer greater
health benefits. More physical activity is required for weight loss and preventing weight regain.
� The evidence reviewed here suggests that mid-age and older women gain few additional health
benefits from vigorous physical activity over and above those achieved from walking or moderate
intensity physical activity. For older women, vigorous physical activity may increase risk of
fractures.
� Few studies have assessed the minimum duration and minimum frequency of physical activity
required to obtain health benefits.
� While 150+ minutes of moderate intensity/week (600+ MET.mins) is associated with a range of
health benefits, there can be significant protective effects against cardiovascular disease, diabetes,
and mental health disorders, from only 60 minutes of moderate intensity physical activity/week
(240 MET.mins/week). Greater amounts of physical activity may be necessary to prevent some
conditions, including breast and colon cancer.
How Active are Australian Mid-age and Older Women?
� Data are presented from the mid-age (45-60 years in 1996-2006) and older (70-85 years in 1996-
2006) cohorts of the Australian Longitudinal Study on Women's Health (ALSWH).
� The proportion of mid-age women meeting or exceeding the National Physical Activity Guidelines
(ie active) increased from 2001 (45%) to 2004 (54%); this was primarily attributable to walking.
Between 2001 and 2004, approximately one third were consistently active, 18% decreased their
physical activity, and 26% increased their physical activity.
� Mid-age women who maintained or increased their physical activity were more likely than those
who were sedentary to have at least high school education, to work part time, have a higher level
of income, and to be a carer for someone with an illness or disability. They were less likely to be
current smokers and non-drinkers, to have chronic health problems, and to be overweight or
obese.
� Mid-age women who decreased their physical activity were more likely than those consistently
active to have a lower level of education, to be a current smoker and non-drinker, to be obese, to
have gained weight, and to have chronic health problems.
xiv
� Life events associated with mid-age women increasing their physical activity included a major
personal achievement, retirement, and death of a spouse. Partner infidelity was associated with
not decreasing physical activity.
� Mid-age women in part-time paid work (1–24 hours per week) and those in 'professional'
occupations (eg teachers and nurses) tended to report higher levels of activity than women in full
time work or in other occupation groups, respectively.
� The proportion of active older women declined from 34 to 30% between 1999 (when they were
73-78 years old) and 2005 (when they were 79-84 years old). The proportion of those who were
sedentary increased from 31 to 44%. During this same period, 26% decreased their activity, and
16% increased their physical activity.
� Older women who maintained or increased their physical activity were more likely than those who
were sedentary to have at least high school education, to have been born outside Australia, and to
be single or widowed. They were less likely to be overweight or obese, and to be a current
smoker, a non-drinker, a carer, or to have chronic health problems.
� Older women who decreased their physical activity were more likely than those consistently active
to be obese, a current smoker, a non-drinker, and to have chronic health problems.
� Life events associated with older women decreasing their physical activity included having a major
personal illness, injury or surgery. No specific life events were associated with older women
increasing their physical activity, although there was a trend for women who reported death of a
spouse not to decrease their physical activity.
Relationships between Physical Activity and Selected Health Outcomes
� Data are presented from the mid-age (45-60 years in 1996-2006) and older (70-85 years in 1996-
2006) cohorts of the Australian Longitudinal Study on Women's Health (ALSWH).
� Changes in physical activity were not related to menopausal symptoms in mid-age women.
� Physical activity did not protect against the development of new arthritis symptoms or arthritis in
mid-age women. Among the older women, 75+ minutes of moderate-intensity physical
activity/week was protective against the onset of stiff or painful joints over a three year period.
Higher levels of physical activity (300+ min/week) were protective against the onset of arthritis
over a three year period.
xv
� Among the older women, very low, low, moderate and high levels of activity (75+ minutes per
week) were associated with lower anxiety and depression scores. Women who reported the
highest level of physical activity (300+ mins/week of moderate intensity physical activity) had the
lowest anxiety and depression scores.
� Memory complaints were slightly less likely among older women who reported high levels of
activity (ie an hour a day or more of moderate intensity physical activity). Low levels of health-
related hardiness and overall mental health were better predictors of memory problems.
� High levels of physical activity were associated with reduced risk of falls, and of broken or
fractured bones in older women who had not had a previous serious fall injury.
� Overall physical and mental well-being scores were significantly higher in mid-age and older
women who were consistently active than in those who were consistently sedentary. These scores
were as high among women whose physical activity increased over time, as they were among
women who were consistently active, indicating that it is never too late to increase physical activity
in order to gain health benefit.
� Physical activity was inversely associated with healthcare costs in both mid-age and older women,
with the greatest differences being between sedentary women and those doing low levels of
activity. For the mid-age women mean costs were 26.3% higher in those who were sedentary
than in moderately active women. For older women mean costs were 23.5% higher in the
sedentary women.
Conclusions
� Physical activity is very beneficial for women's health at the population level. Physical activity has
a significant role in the primary prevention of cardiovascular disease, some cancers, diabetes,
mental health problems, and musculoskeletal problems in women. Physical activity has also been
shown to reduce healthcare costs. Importantly, there are benefits for women who become active
later in life, even if they have been sedentary for a long time.
� There is a strong rationale for greater investment in the promotion of physical activity as a
strategy for the primary prevention of a range of chronic health problems in women.
xvi
Physical Activity and Health – Updating the Evidence for Women
1Physical Activity and Health in Mid-Age and Older Women
1. PHYSICAL ACTIVITY AND HEALTHUPDATING THE EVIDENCE FOR WOMEN
1.1 Introduction
2006 marks the ten year anniversary of the landmark US Surgeon
General's (USSG) Report on Physical Activity and Health (US Department
of Health and Human Services, 1996). Released on the eve of the
Centennial Olympic Games in Atlanta, the report espoused lifelong
participation in moderate physical activity, rather than scaling Olympian
heights to achieve health benefits.
The report documented the extent and strength of the evidence relating
physical activity to health benefits, especially in the area of coronary heart disease, diabetes,
hypertension, colon cancer, mental health, musculoskeletal health, and independence in older adults.
A striking feature of the report's section on physical activity and cardiovascular disease was that only
four of the thirty six cited studies included data from women. The largest of the early cohort studies
which assessed physical activity included Morris's studies of London Transport workers (Morris, Kagan,
Pattison, Gardner & Raffle, 1966) and British civil servants (Morris, Everitt, Pollard, Chave, &
Semmence, 1980); Paffenbarger's studies of Harvard Alumni (Paffenbarger, Wing, & Hyde, 1978) and
San Francisco longshoremen (Paffenbarger & Hale, 1975); Taylor's study of US railroad industry
employees (Taylor, Klepetar, Keys, Parlin, Blackburn, & Puchner, 1962); Shaper and Wannamethee's
(1991) British Regional Heart Study; and the Lipid Research Clinics prevalence survey (Ekelund,
Haskell, Johnson, Whaley, Criqui, & Sheps, 1988), all of which only included men.
A tally of the studies linking physical activity with other health outcomes in the USSG report shows that
fewer than 5% of all participants in these studies were women. Even in the area of cancer
epidemiology, male participants in the studies of prostate cancer outnumbered the women involved in
the breast cancer studies by two to one. It is therefore timely on this tenth anniversary of the USSG
report to explore the evidence relating to physical activity and health in women. In the first part of
this report, we review the recent evidence relating physical activity to the primary prevention of six of
the national public health priority areas in women. The focus is exclusively on adults, and particularly
on women aged 45 years and over, who are most at risk of developing health problems related to
inactivity.
2
A focus on primary prevention
Since 1996 over one thousand papers have been published that discuss the health benefits of physical
activity in women. Because of the sheer volume of this literature, and our belief that in order to
improve population health outcomes there is a need to increase attention in the area of primary
prevention, we chose to restrict this review to population-based primary prevention studies. The
review therefore focuses on results from large cohort studies that consider the evidence for a role of
physical activity in the prevention of those health conditions that cause most ill health and disability in
Australian women – namely the six public health priority areas of cardiovascular disease, cancer,
diabetes, mental health problems, musculoskeletal problems and injury (fracture). Asthma is not
included as there is little evidence to suggest that physical activity has a role in the primary prevention
of asthma, though it certainly has a role in asthma management.
We have not included studies of physical activity and risk factors for these conditions [eg blood
pressure, blood lipids (for cardiovascular disease), elevated blood glucose (for diabetes), bone density
or osteoporosis (for fracture)], focusing instead only on studies of physical activity and the six specific
health outcomes. In light of its explicit relevance for women's health, we have however also included
a short section on the evidence relating physical activity and several reproductive health issues.
Although physical activity is now widely accepted as an important factor in the secondary and tertiary
prevention (ie management) of chronic disease, most of the evidence comes from rehabilitation trials
that focus on exercise tolerance or psychosocial status and risk factors rather than on long term health
outcomes. Few of these studies have had sufficiently long follow-up to assess long term health
outcomes. Most of the studies have been conducted with convenient volunteer samples, and few have
been translated for more widespread intervention.
In terms of secondary prevention it should however be acknowledged that there is now good evidence
to support a role for physical activity in the secondary prevention of cardiovascular disease (eg through
reducing high blood pressure and lipid levels) and diabetes (eg through reducing raised blood glucose
and body mass index; Bauman, 2004). There is also strong evidence to support the role of physical
activity in the tertiary prevention or management of cardiovascular disease, diabetes and injury, and
growing evidence to support its role in the management of some cancers and mental health problems
(Pedersen & Saltin, 2006).
Physical Activity and Health – Updating the Evidence for Women
3
Physical Activity and Health in Mid-Age and Older Women
PRIMARY PREVENTION
aims to prevent the occurrence of poor health in individuals and
to reduce the incidence of conditions in the population.
SECONDARY PREVENTION
aims to identify and intervene with people in the early stages of
poor health, so as to slow the progression, lessen duration, or
prevent a more serious condition developing.
TERTIARY PREVENTION
aims to reduce and minimise the complications, disability, and
suffering associated with poor health
4
1.2 Methods
A literature search was conducted to identify existing evidence on the effectiveness of physical activity
for primary prevention. CINAHL, PRE CINAHL, PSYCHINFO, PSYCHLIT and MEDLINE electronic
databases were utilised with the following search terms: physical activity, exercise, female, women,
longitudinal, prospective, cohort, health, diabetes, cancer, arthritis, cardiovascular, coronary,
musculoskeletal, injury, mental, psychological, cognitive, mortality. The search was limited to those
studies published from 1997 to January 2006, and written in English. The titles and abstracts of
identified articles were checked for relevance by two of the authors of this report (NB, WB).
Only prospective population-based studies, where physical activity was a primary study variable, were
included. Evidence from clinical or small scale trials, or studies that assessed physical activity as a
treatment or as an effect modifier, were not considered. Reviews and meta-analyses of the
association between physical activity and the identified health conditions were also considered, as well
as individual publications mentioned in these studies. Studies that included both men and women
were included if results were stratified by gender. The reference lists of relevant articles were checked
for additional papers.
Interpreting the data – The importance of the physical activity measure
In all the studies reviewed here, the relationships between physical activity and the outcome of
interest vary significantly according to the method of measuring physical activity. For logistical
reasons, few studies have included objective measures of physical activity, though the prospective
studies conducted at the Cooper Clinic (Aerobics Centre Longitudinal Study) measured aerobic capacity
as an indicator of fitness (Farrell, Braun, Barlow, Cheng, & Blair, 2002).
In a meta-analysis of heart disease risk factors, it was noted that, in general, studies which have
measured fitness showed stronger relationships with health outcomes than those which rely on self
report measures (Williams, 2001). However, the self report measure used in the US Nurses Health
Study (NHS) has been validated and shown to have good measurement properties compared with
detailed diary records of physical activity (Wolf, Hunter, Colditz, et al., 1994).
Physical Activity and Health – Updating the Evidence for Women
5
Physical Activity and Health in Mid-Age and Older Women
Most of the more recent large US cohort studies (beginning with the NHS which was established in
1976) have derived estimates of total energy expenditure from responses to questions about time
spent in walking, and in moderate- and vigorous-intensity physical activity. The results of these
studies have been used to assess the frequency, intensity and duration (or dose) of physical activity
associated with specific health outcomes. In general, studies using measures of energy expenditure
show more consistent estimates of risk reduction than those that rely only on measures of frequency
or on responses to more generic physical activity questions.
Some studies have asked more detailed questions about specific forms of physical activity or
participation in selected sports and recreational activities. For example, the University of Pennsylvania
alumni study, which was established in 1962, used questions based on those developed by
Paffenbarger for the Harvard Alumni study which assess blocks walked, stairs climbed and participation
in organised sports (Paffenbarger, Wing, & Hyde, 1978). The Pennsylvania alumni study did not
however, find significant associations between physical activity and cardiovascular disease in women,
except in women who walked more than 10 blocks per day (Sesso, Paffenbarger, Ha, & Lee, 1999).
This may be because walking was reported more precisely than the other activities, or because the
women did not typically engage in stair climbing or organised sports.
These questions were modified for the US Women's Health Study (WHS), a trial that began in 1992
and is assessing the effects of aspirin and vitamin E in the prevention of cardiovascular disease and
cancer (Buring & Hennekens, 1992a, 1992b). Their questions focus on recreational activities typically
undertaken by women, including walking and stair climbing. Although time in each activity is
converted to an overall estimate of energy expenditure (kJ), this is one of few studies that is able to
accurately assess participation in activities of different intensity, as it does not rely on responses to
more generic questions about moderate and vigorous physical activity.
Few studies have focused on both occupational and leisure-time activity, and those that have, have
mostly included only men. Recent exceptions are the Buffalo Health Study (Dorn, Cerny, Epstein,
Naughton, Vena, Winkelstein, et al., 1999) and the Canadian Fitness Study (Weller & Corey, 1998)
which included detailed questions about work-related as well as leisure time physical activity.
Measurement of work-related physical activity has however proven to be especially challenging in
women – particularly among women who do not have consistent patterns of physical activity in their
paid and unpaid work. Although Canadian researchers have estimated that household work accounts
for 82% of women's physical activity (Weller & Corey, 1998), it is not known whether contemporary
household activities are carried out at an intensity that is sufficient to elicit health benefits (Brown,
Trost, Ringuet, & Jenkins, 2001).
6
Studies that use global or single item self assessment of physical activity, those that emphasise
participation in organised sport and work-related vigorous activity, and those that rely on individual
perceptions of fitness, do not demonstrate strong relationships between physical activity and health
outcomes in women. This is likely to be because the measures do not capture the true nature or
volume of physical activity undertaken by participants. Because of the limitations imposed by these
and other more generic measures, results from those studies with more detailed physical activity
measures are specifically highlighted in this report.
Physical Activity and Health – Updating the Evidence for Women
7
Physical Activity and Health in Mid-Age and Older Women
Other methodological considerations
In considering the evidence presented here, it is also important to consider the age of participants at
baseline and the duration of follow-up of the cohort. As the incidence of most health problems
increases with age, it is more likely that there will be sufficient events for detection in the analyses if
participants are older, and if there is a long follow-up period.
For rare events, such as bladder cancer, very large samples are required, such as those established for
the NHS I (N=121,000), NHS II (N=116,000) (Colditz & Hankinson, 2005) and the Women's Health
Initiative Observational Study (WHI) (N=74,000) (Manson, Greenland, LaCroix, Stefanick, Mouton,
Oberman, et al., 2002). For studies with smaller numbers of women, such as the Pennsylvania alumni
study, smaller samples can show significant results when there is a long period of follow-up – in that
case the cohort has now been followed for more than 30 years (Sesso et al., 1999). The NHS and
WHI studies have published analyses based on data collected for between 6 and 16 years, allowing
several hundred thousand person-years of follow-up, and providing ample power to detect the
incidence of rare or less common health problems.
An important characteristic of the more recent large cohort studies is that the researchers are able to
adjust for the effects of a range of potential confounders, including risk behaviours such as smoking
and drinking alcohol, diet (fat, fibre, fruit and vegetables), use of menopausal hormones, body
composition and size (body mass index, waist to hip ratio), body fat, other chronic diseases such as
diabetes, and biological markers such as cholesterol and blood pressure. In most studies, inclusion of
these confounders attenuates the relationships between physical activity and health outcomes.
Results with the highest level of adjustment have been selected for inclusion in the tables and figures
in this report. This means that the estimates are conservative and do not take into account the
additional favourable effects of physical activity on adiposity and other intermediate risk factors such
as cholesterol and blood pressure (Manson et al., 2002).
8
1.3 Cardiovascular Disease
The USSG report found an inverse association and a dose-response
relationship between physical activity or cardiorespiratory fitness and both
cardiovascular disease (CVD) in general and coronary heart disease (CHD)
specifically (US Department of Health and Human Services, 1996). The
level of risk reduction with regular physical activity was noted to be similar
to that of other behavioural risk factors such as not smoking. There were
no conclusive data relating physical activity and stroke, and only 2% of
participants in the reviewed studies were women.
For this review we found 17 new studies of physical activity and several different cardiovascular
outcomes in women, published since 1997 (see Appendix A). Previous researchers have noted that
the relationship between physical activity and CVD outcomes is less consistent in women than in men
and have suggested that this could be explained by measurement error associated with assessment of
physical activity in women (Sesso, Paffenbarger, Ha, & Lee, 1999).
The five new studies which focused on CVD or CHD mortality support this view, with one showing little
or no relationship (Dorn, Cerney, Epstein, Naughton, Vena, Winkelstein, et al., 1999), and three
finding significant associations between physical activity and CVD mortality (Gregg, Cauley, Stone,
Thompson, Bauer, Cummings, et al., 2003; Kushi, Fee, Folsom, Mink, Anderson, & Sellers, 1997;
Weller & Corey, 1998). One study found no relationship after 10 years (Haapanen, Miilunpalo, Vuori,
Oja, & Pasanen, 1997), but then reported a significant association after 16 years (Haapanen-Niemi,
Miilunpalo, Pasanen, Vuori, Oja, Malmberg, 2000).
In general, three of the studies, [the Study of Osteoporotic Fractures (SOF; 7553 women aged 65
years or more; Gregg et al., 2003); the Iowa Women's Health Study (40,417 post-menopausal women;
Kushi et al., 1997); and the Canadian Fitness Study (6,620 women aged 30 years or more; Weller &
Corey 1998)] had much stronger measures of physical activity. Importantly, both the SOF (Gregg et
al., 2003) and Iowa (Kushi et al., 1997) studies reported that the risk reductions associated with
walking or moderate intensity activity (mPA) were similar to those observed for total physical activity.
The Iowa researchers reported a significant inverse association between any regular physical activity
and CVD mortality (RR=0.72, 95% CI 0.54, 0.95; Kushi et al., 1997). In the Canadian study, there
was a significant reduction in risk of CVD mortality with non-leisure physical activity (Weller & Corey,
1998; see Table 1). This is one of the only studies to show that women's work-related physical activity
may be linked to CVD risk in the same way as has been reported for men.
Physical Activity and Health – Updating the Evidence for Women
9
Physical Activity and Health in Mid-Age and Older Women
The SOF (which was set up to explore risk factors for fracture) also found that women who became
active later in life had rates of CVD mortality similar to those of women who maintained their level of
activity from baseline (Gregg et al., 2003). In this study, recent physical activity was a more
significant predictor of longevity than past physical activity. It is possible that the higher levels of high
density lipoprotein cholesterol (HDL-C) in pre-menopausal women confer an advantage in terms of
heart disease risk, so that physical activity becomes even more important in terms of reducing heart
disease risk in post-menopausal women, when HDL-C levels are lower.
New data from three of the large US women's cohort studies [the Women's Health Study with almost
40,000 women (Lee, Rexrode, Cook, Manson & Buring, 2001); the Women's Health Initiative (Manson,
Greenland, LaCroix et al., 2002) and the Nurses' Health Study (Manson, Hu, Rich-Edwards et al.,
1999), each with more than 70,000 women] have now shown significant associations between physical
activity and reduced risk of incident coronary heart disease and coronary events (see Figure 1.1).
These results suggest that participation in activities that expend the energy equivalent of as little as
one to three hours a week of moderate intensity physical activity is associated with a 20-30%
reduction in these cardiovascular health outcomes. Increasing the energy expenditure of physical
activity (either through increasing intensity or activity time) results in further reductions in the risk of
CVD (relative risk; RR as low as 0.47, 95% CI 0.33, 0.67; see Appendix A).
The US Surgeon General's report did not find a consistent relationship between physical activity and
stroke (US Department of Health and Human Services, 1996). In contrast, data from studies of four
large cohorts of women now provide strong evidence of a graded inverse relationship between
physical activity and risk of ischaemic stroke in women (Ellekjaer, Holman, Ellekjar, & Vatten, 2000;
Hu, Stampfer, Colditz, Ascherio, Rexrode, Willett, et al., 2000; Nakayama, Date, Yokoyama, Yoshiike,
Yamaguchi, & Tanaka, 1997; Paganini-Hill & Barreto, 2001).
Data from several of these studies support the notion that the benefits of physical activity can be
realised with brisk walking. Among women who do not do any other form of physical activity, as little
as one hour of walking per week at a rate of only 3.2 – 4.8 km/hour is associated with a relative risk
reduction for several CVD outcomes, including stroke, of 18-50% (Hu et al., 2000; Manson et al.,
2002; Manson, Hu, Rich-Edwards, Colditz, Stampfer, & Illett, 1999). Compliance with national
guidelines is associated with a further reduction in risk, with an average of relative risk of about 0.62
for 10 MET.hours per week of walking (2.5 hours) (see Figure 1.2 and Appendix A).
10
For women who walk, these studies also show that the speed of walking is important. The average
relative risk for cardiovascular outcomes among women who walk at 3.2–4.8 km/hour is 0.78, while
for those who walk faster (4.8–6.4 km/hour) the average relative risk for these cardiovascular
outcomes (CHD, CVD, events and stroke) is about 0.60, compared with those who walk more slowly
(see Figure 1.3 and Appendix A).
There is therefore now accumulating evidence which confirms the dose-response relationship between
physical activity and several different cardiovascular health problems in women, with new evidence to
show the importance of physical activity in preventing stroke. The risk reductions are around 20% for
minimal compliance with guidelines and up to 58% for increased volumes (which can be through
increased duration, frequency or intensity) of activity.
Physical Activity and Health – Updating the Evidence for Women
11
Physical Activity and Health in Mid-Age and Older Women
0.4
0.5
0.6
0.7
0.8
0.9
1
1 (low) 2 3 4 5 (high)
Physical activity level
Rel
ativ
e ris
k of
car
diov
ascu
lar
outc
omes
Ellekjaer et al., 2000 Hu et al., 2000 (stroke)Lee et al., 2001 (CHD) Manson et al., 2002 (CVD)Manson et al., 2002 (CHD)
Figure 1.1 Relative risk of cardiovascular disease outcomes by approximate quintiles of physical activity.
Meeting guidelines
12
0.4
0.5
0.6
0.7
0.8
0.9
1
1 (low) 2 3 4 5 (high)
Level of walking
Rela
tive
risk
of c
ardi
ovas
cula
r ou
tcom
es
Manson et al., 2000 (events)Hu et al., 2000 (stroke)Lee et al., 2001 (CHD)Manson et al., 2002 (CVD)Manson et al., 2002 (CHD)
Figure 1.2 Relative risk of cardiovascular disease outcomes by approximate quintiles of walking.
Meeting guidelines
Physical Activity and Health – Updating the Evidence for Women
13
Physical Activity and Health in Mid-Age and Older Women
0.4
0.5
0.6
0.7
0.8
0.9
1
1.1
none easy moderate brisk very fast
Walking pace
Rel
ativ
e ris
k of
car
diov
ascu
lar
outc
omes
Lee et al., 2001 (CHD) Hu et al., 2000 (stroke)Manson et al., 2002 (CVD) Manson et al., 1999 (events)
Figure 1.3 Relative risk of cardiovascular disease outcomes by walking pace.
14
1.4 Type 2 Diabetes
As was the case for cardiovascular disease, the US Surgeon
General's report found that regular physical activity lowered
the risk of developing non-insulin-dependent diabetes
mellitus (NIDDM) (US Department of Health and Human
Services, 1996). At that time, three large US cohort studies
[the male college alumni study (Helmrich, Ragland, Leung, &
Paffenbarger 1991); the male physicians study (Manson,
Rimm, Stampfer, Coldtiz, Willett, Krolewski, et al., 1991);
and the NHS (Manson, Nathan, Krolwewski, Stampfer, Willett, & Hennekens, 1992)] had provided
good evidence of significant reductions in risk of NIDDM with quite small increments in physical
activity.
For this review we found eight new reports on the role of physical activity in the primary prevention of
type 2 diabetes in women. (The term diabetes will be used here for type 2 diabetes as the term
NIDDM is not now routinely used). The three large US women's cohort studies including the NHS
(Hu, Li, Colditz, Willett, & Manson 2003; Hu, Sigal, Rich-Edwards, Colditz, Solomon, Willett, et al.,
1999), the WHI (Hsia, Wu, Allen, Oberman, Lawson, Torrens, et al., 2005) and the Women's Health
Study (Weinstein, Sesso, Lee, Cook, Manson, Buring, et al., 2004) have all reported independent
associations between physical activity and incidence of diabetes (See Figure 1.4 and Appendix B).
Interestingly, the most recent report from the WHI found this relationship only in Caucasian women,
and not in African-American, Hispanic or Asian/Pacific Islander women (Hsia et al., 2005). The
researchers considered one explanation for this observation might be that the non-Caucasian women
did not perform sufficient physical activity to reach a hypothetical threshold for benefit. While they
confirmed that the African-American and Hispanic (but not the Asian) women were less active, when
they compared women with equivalent levels of physical activity they could not find any compelling
evidence for an association between physical activity and diabetes prevention in non-Caucasian
women. It was stressed that these findings are provocative rather than definitive, and require further
research.
Physical Activity and Health – Updating the Evidence for Women
15
Physical Activity and Health in Mid-Age and Older Women
0.4
0.5
0.6
0.7
0.8
0.9
1
1.1
1 (low) 2 3 4 5 (high)
Physical activity level
Rel
ativ
e ris
k of
dia
bete
s
Folsom et al., 2000 Hsia et al., 2005
Hu et al., 1999 Weinstein et al., 2004
Figure 1.4 Relative risk of diabetes by approximate quintiles of physical activity.
Meeting guidelines
16
In another study involving a different ethnic group, Kriska, Saremi, Hanson, et al., (2003) found a
significant association between total physical activity and incident diabetes in a group of Pima Indians
in Arizona. The relationship was however attenuated after adjustment for age and body mass index.
This smaller study (approximately 1000 women) is the only cohort study to have used an objective
measure of diabetes (oral glucose tolerance test) instead of self-report. Both the NHS and the WHS
have however, conducted sub-studies to verify self-report of diabetes. The NHS reported that 98% of
their sub-sample of 62 women was confirmed to have diabetes (Manson et al., 1991) and the WHS
confirmed the self report of diabetes in 91% of their sub-sample of 473 women (Weinstein et al.,
2004).
Since 1997 the NHS researchers have published several important papers on physical activity and
diabetes. One focused on the potential benefits of walking for diabetes prevention (Hu et al., 1999).
Using data from eight years of follow-up, the researchers found a significant inverse association
between energy expenditure from walking and risk of diabetes, with increased risk reduction with
faster pace of walking (see Figure 1.5 and Appendix B). The researchers concluded that equivalent
energy expenditures from moderate and vigorous physical activity may confer similar benefits, with
each additional hour per day of brisk walking associated with a 34% reduction in diabetes.
A second paper from the NHS, published in 2003, with data from six years of follow-up, reported that
independent of exercise levels, sedentary behaviours, especially watching television, were associated
with significantly increased risk of diabetes (Hu et al., 2003). Sedentary occupations (ie long hours of
sitting or standing at work) were significantly associated with higher body mass index but not with
diabetes, and even light activities, such as standing or walking around at home (household work) and
brisk walking were each associated with significantly reduced risk of both obesity and diabetes.
The WHS has reported very similar findings to those from NHS. The WHS researchers also compared
the relative contributions of body mass index and physical activity to diabetes risk reduction (Weinstein
et al., 2004). They found that although physical activity and body mass index are both independent
predictors of incident diabetes, the magnitude of the association with body mass index was greater
than for physical activity, emphasizing the critical role of adiposity in the development of diabetes.
Physical Activity and Health – Updating the Evidence for Women
17
Physical Activity and Health in Mid-Age and Older Women
0.5
0.6
0.7
0.8
0.9
1
1 (low) 2 3 4 5 (high)
Level of walking
Rel
ativ
e ris
k of
dia
bete
s
Hsia et al., 2005 Hu et al., 1999
Weinstein et al., 2004
Figure 1.5 Relative risk of diabetes by approximate quintiles of walking.
Meeting guidelines
18
A note about the secondary prevention trials for diabetes
In the area of diabetes prevention, it is important to note that, since publication of the USSG report
(US Department of Health and Human Services, 1996), there have been several landmark studies of
the role of physical activity in the secondary prevention of diabetes in at risk individuals (ie those with
elevated blood glucose but not diabetes). These randomised controlled trials, which included both
male and female participants, have shown reduced progression to diabetes with increased physical
activity, and in most cases, weight loss. The Diabetes Prevention Program (which included 1043 men
and 2191 women) found that lifestyle modification (including physical activity, dietary change and
weight loss) was more beneficial than metformin in reducing the development of diabetes (Knowler,
Barrett-Connor, Fowler, Hamman, Lachin, Walker, et al., 2002). An earlier randomised controlled trial
in Finland (172 men and 350 women) also found that improvement in diet and exercise reduced the
risk of diabetes, even if target weight loss goals were not reached (Tuomilheto, Lindstrom, Eriksson,
Valle, Hamalainen, Ilanne-Parikka, et al., 2001) and the Da Qing study in China (283 men and 247
women) found similar risk reductions for both diet and physical activity intervention groups (Pan, Li,
Hu, Wang, Yang, An, et al., 1997).
The self reported prevalence of diabetes in Australia has more than
doubled since 1989-90.
The proportion of people reporting diabetes increases with age. The
highest prevalence of diabetes is among those aged 65-74 years.
More than 1 in 14 people older than 25 years of age has diabetes, and
about half of these people are not aware that they have diabetes.
AIHW, 2006
Physical Activity and Health – Updating the Evidence for Women
19
Physical Activity and Health in Mid-Age and Older Women
Gestational diabetes
In light of the evidence relating physical inactivity to the development of diabetes,
there is increasing interest in the role of physical activity in gestational diabetes
(GDM). The USSG report (US Department of Health and Human Services, 1996) did
not include any consideration of gestational diabetes. Although exercise during
pregnancy is not directly relevant to all mid-age and older women, this is an
important issue because women who have gestational diabetes are more likely to develop type 2
diabetes.
The NHS II, which began in 1989, has explored determinants of GDM in their very large (N >116,000)
cohort of female nurses (Solomon, Willett, Carey, Rich-Edwards, Hunter, Colditz et al., 1997). They
found no association between pregravid total physical activity and GDM risk, and non-significant
associations between both self reported pre-pregnancy vigorous physical activity and brisk walking and
relative risk of GDM (see Appendix C).
In contrast, the smaller OMEGA study, (N=909) which was designed to explore risk factors for pre-
eclampsia, found that women who were physically active both prior to and during pregnancy had a
69% reduced risk of GDM, even after adjustment for age, race, parity and pre-pregnancy body mass
index (Dempsey, Sorensen, Williams, Lee, Miller, Dashow, et al., 2004; see Appendix C). These
conflicting data suggest that more research is necessary to elucidate the role of physical activity in
GDM, and the impact of post-pregnancy physical activity on the risk of developing type 2 diabetes in
mid-age.
Gestational diabetes affects 5-9% of pregnancies in
Australian women.
Cheung & Byth, 2003
Women with gestational diabetes are six times more likely to
develop type 2 diabetes later in life than women without
gestational diabetes. Up to 50% of women who have had
gestational diabetes develop type 2 diabetes.
O'Sullivan, 1991
20
Australia has the fifth highest incidence of cancer in women in the world.
The most common types of cancer are breast cancer, colorectal cancer,
melanoma, and lung cancer, accounting for 60% of all registered cancer
cases in Australian women in 2001.
26% of deaths among women in 2004 were cancer related.
Cancer is the leading cause of death among women aged 45-64 years,
accounting for 57% of all deaths in 2004.
1 in 4 women will be diagnosed with cancer by 75 years of age.
1 in 11 women will die from a malignant cancer before 75 years of age,
and 1 in 6 will die before 85 years of age.
AIHW, 2006
3.5 Cancer
The US Surgeon General's Report examined the evidence for relationships
between physical activity and a range of cancers, and concluded that regular
physical activity was associated with a decreased risk of colon cancer, but the
relationship between physical activity and breast cancer was "inconsistent"
(US Department of Health and Human Services, 1996).
Physical Activity and Health – Updating the Evidence for Women
21
Physical Activity and Health in Mid-Age and Older Women
Breast cancer
As the most commonly occurring cancer in Australian women
(Australian Bureau of Statistics, 2001), the evidence relating to
physical activity and the primary prevention of breast cancer is of
particular interest. At the time of the USSG report there was
insufficient evidence to support an association (US Department of
Health and Human Services, 1996). Our review, however, identified
ten new cohort studies with comprehensive measures of physical
activity published since 1997 and the results of these are summarised in Appendix D.
Both the Women's Health Initiative (WHI) (McTiernan, Kooperberg, White, Wilcox, Coates, Adams-
Campbell et al., 2003) and the 16 year follow-up of the NHS reported significantly reduced risk of
breast cancer in women with higher total (moderate and vigorous) physical activity. In the NHS, the
cumulative average of physical activity (assessed biennially over 14 years) showed a reduction in risk
of incident breast cancer over 16 years of 18% (RR=0.82; 95% CI 0.70-0.97), for women reporting >7
hours per week of moderate intensity physical activity and vigorous physical activity (Rockhill, Willett,
Hunter, Manson, Hankinson, & Colditz, 1999).
An analysis of data from more than 40,000 women in the French E3N cohort also found a linear
decrease in risk of breast cancer with increasing amounts of both moderate and vigorous recreational
activity (Tehard, Friedenreich, Oppert, & Clavel-Chapelon, 2006). Women who reported more than
five hours of weekly recreational physical activity had a relative risk of breast cancer of 0.62 (95% CI
0.49-0.78). The relationships were consistent in overweight women, those with a family history of
breast cancer, and in hormone replacement therapy users. The risk reduction was greatest for
nulliparous women. Although the measure was less comprehensive, the Norwegian study by Thune,
Brenn, Lund, & Gaard (1997) also reported a significant association between both leisure-time physical
activity (LTPA) and occupational physical activity, with decreased risk of breast cancer. The risk
reduction was stronger in pre-menopausal women than in post-menopausal women, and in women
younger than 45 years of age than those older than 45 years of age.
In contrast, both the US WHS (Lee, Rexrode, Cook, Hennekens, & Buring 2001) and the Iowa
Women's Health Study (Moore, Folsom, Hong, Anderson, & Kushi, 2000) found that physical activity
during mid-age is not significantly associated with decreased risk of breast cancer. There was a
significant association between physical activity and breast cancer risk in women aged 55 years or
more in the smaller Pennsylvania State Alumni study (Sesso, Paffenbarger, & Lee, 1998).
22
0.4
0.5
0.6
0.7
0.8
0.9
1
1.1
1 (low) 2 3 4 5 (high)
Level of physical activity
Rel
ativ
e ris
k of
bre
ast
canc
er
Thune et al., 1997 Rockhill et al., 1999Luoto et al., 2000 McTiernan et al., 2003Lee et al., 2001 Tehard et al., 2006
Figure 1.6 Relative risk of breast cancer by approximate quintiles of physical activity.
Meeting guidelines
Physical Activity and Health – Updating the Evidence for Women
23
Physical Activity and Health in Mid-Age and Older Women
The majority of these findings confirm a modest inverse association between higher volumes of
moderate intensity physical activity and vigorous physical activity and breast cancer risk, especially
when a cumulative measure is used (see Figure 1.6). Although the NHS result using a cumulative
measure (Rockhill et al., 1999) might imply that lifetime physical activity is important in the prevention
of breast cancer, it is also possible that the cumulative measure simply gives a better indication of
physical activity than a single one week recall, which would be more likely to result in misclassification
of physical activity.
It is still unclear whether the relationship is stronger in post-menopausal than in pre-menopausal
women though the WHS found this to be the case, with post-menopausal women who expended �
6300 kJ/week (equivalent to walking 24 km or about 6 hours/week) experiencing a risk reduction of
33% compared with those who expended <840 kJ/week (Lee, Rexrode, Cook, Hennekens, & Buring,
2001). In her 2003 review of this evidence, Lee (2003) reported that the median relative risk for all
studies published (including those prior to 1996) is about 0.8 for pre-menopausal and 0.7 for post-
menopausal women.
There is still debate about whether vigorous intensity physical activity is more likely to reduce risk of
breast cancer than more moderate or mixed forms of physical activity. The results of several studies
on vigorous activity and risk of breast cancer are presented in Figure 1.7. As very high levels of
exercise and training can reduce the number of ovulatory menstrual cycles, it has been hypothesised
that this might be the mechanism by which physical activity impacts on breast cancer risk. However,
with the exception of data from the French E3N study (Tehard et al., 2006), the results reported here
do not appear to support the argument that vigorous intensity is necessary for optimal risk reduction.
For example, in the NHS, the most popular form of physical activity was walking, (comprising more
than 40% of all the moderate and vigorous physical activity reported) and the risk reduction in that
study and in the WHI study was greater in the mixed group than in the vigorous only group
(McTiernan et al., 2003; Rockhill et al., 1999). Moreover, the WHS, which ran a separate analysis for
women who reported activities with an intensity > 6 METs, found no significant relationship between
participation in vigorous activity and risk of breast cancer (Lee et al., 2001). In any event it is unlikely
that exercise equivalent to daily athletic training is required to reduce the risk of breast cancer, as few
of the women included in these large cohorts exercise at this level of intensity (McTiernan et al.,
2003).
24
0.4
0.5
0.6
0.7
0.8
0.9
1
1 (low) 2 3 4 5 (high)
Level of vigorous-intensity physical activity
Rel
ativ
e ris
k of
bre
ast
canc
er
Rockhill et al., 1999 McTiernan et al., 2003Lee et al., 2001 Tehard et al., 2006
Figure 1.7 Relative risk of breast cancer by approximate quintiles of vigorous physical
activity.
Physical Activity and Health – Updating the Evidence for Women
25
Physical Activity and Health in Mid-Age and Older Women
Breast cancer is the most common type of cancer in women.
1 in 11 women are at risk of breast cancer.
In 2004, breast cancer accounted for 14% of deaths in women
aged 45-64 years.
AIHW, 2006
The mechanism of the association between physical activity and breast cancer risk is not clear. It is
likely to involve energy balance and complex inter-relationships between fat metabolism and
reproductive hormones. It is therefore important to acknowledge that these analyses have been
adjusted statistically for potential confounders such as use of oral contraceptives and hormone
replacement therapy, parity and menopausal status, and it is acknowledged that body mass index and
weight change might be intermediate variables through which physical activity reduces the risk of
breast cancer.
These data support a role for leisure-time physical activity as an independent and modifiable strategy
for reducing the risk of breast cancer. Many studies have shown a clear dose-response relationship,
with women who report at least one hour a day of physical activity having a 15-30% reduced risk of
breast cancer. Most of the results point to the importance of avoiding obesity if physical activity is to
have an optimal impact on risk of breast cancer (McTiernan et al., 2003; Thune et al 1997), and,
importantly, the findings of the WHI and E3N studies suggest that physical activity can also reduce risk
of breast cancer in women who are using hormone replacement therapy.
26
Colon cancer
As was the case for coronary heart disease, the evidence in the USSG report (US Department of Health
and Human Services, 1996) about physical activity and colorectal cancer came predominantly from
studies involving men. The largest cohort studies reviewed were the US alumni (Paffenbarger, Hyde,
& Wing, 1987) and the health professionals' (Giovannucci, Ascherio, Rimm, Colditz, Stampfer, &
Willett, 1995) studies. Fewer than 3% of the participants in all the studies reviewed were women.
Both occupational and leisure-time physical activity had a protective effect on the risk of developing
colon cancer, but not rectal cancer (US Department of Health and Human Services, 1996).
For this review we found three more recent large cohort studies that examined this relationship in
women (see Appendix E). The NHS followed 67,802 women for six years and was the first study to
report a significant inverse association between average weekly leisure time physical activity (based on
moderate intensity physical activity and vigorous physical activity) and incident colon cancer in women
(Martinez, Giovannucci, Speigelman, Hunter, Willett, & Colditz, 1997). This may be because previous
studies had focused on colorectal cancer (eg Thune & Lund, 1996) or on occupational measures of
physical activity which are problematic in women (Martinez et al., 1997). The NHS found that women
who reported >21 MET.hours of physical activity per week (equivalent to about 5 hours of moderate
physical activity) had almost half the risk of colon cancer, compared with the most sedentary women
(Martinez et al., 1997).
For moderate physical activity only, the relative risk for those reporting an hour or more per day was
0.69 (95% CI 0.52-0.90) and for vigorous physical activity, the relative risk for those reporting more
than 30 mins per day was 0.61 (0.43-0.86) (Martinez et al., 1997). Researchers working with the US
Cancer Prevention cohort established in 1992 with almost 100,000 older women (50-74 years), also
found a significant inverse association between risk of colon cancer and time spent in walking and
other physical activity (Chao, Connell, Jacobs, McCullough, Patel, Calle et al., 2004). However among
women who reported only walking, there was no significant association.
In contrast to these two US reports, the Norwegian study, which included almost 40,000 women who
were followed for 10-12 years, found no independent association between physical activity and
incident colon cancer, but noted that risk of colon cancer was associated with diabetes and high blood
glucose in women (Lund Nilsen & Vatten, 2001).
Colorectal cancer is the second most common type of cancer among
women, accounting for 14% of all cancers, and 13% of all cancer
deaths in 2001. 1 in 26 women are at risk of colorectal cancer.
AIHW, 2006
Physical Activity and Health – Updating the Evidence for Women
27
Physical Activity and Health in Mid-Age and Older Women
Other cancers
Since the publication of the USSG (US Department of Health and Human
Services, 1996) there has been more research into the relationship between
physical activity and reproductive (ovarian and endometrial) cancers,
but the relationships remain equivocal. For example, both the 15 year follow-
up of the Iowa WHS (Andersen, Ross & Folsom, 2004) and the 16 year
follow-up of the NHS (Bertone, Willett, Rosner, Hunter, Fuchs, Speizer et al.,
2001) analysis found some suggestion of a positive relationship between
physical activity and increased risk of ovarian cancer.
In contrast, data from the Swedish census study reported a trend towards increasing risk of
endometrial cancer with decreasing levels of occupational physical activity in women aged 50-69
years (Moradi, Nyren, Bergstrom, Gridley, Linet, Wolk et al., 1998), and data from the Swedish Twin
Registry showed markedly decreased incident endometrial cancer with increasing levels of physical
activity (based on a very poor measure of physical activity) (Terry, Baron, Weiderpass, Yuen,
Lichtenstein, & Nyren, 1999) (see Appendix F).
For this review we also found three recent studies of pancreatic cancer – none of which showed any
significant relationships, although there was a trend towards decreasing risk of pancreatic cancer with
increasing levels of moderate physical activity and walking/hiking in the combined analysis of data
from the health professionals and nurses studies (Michaud, Giovannucci, Willett, Colditz, Stampfer, &
Fuchs, 2001). In this study, individuals with a body mass index (BMI) >30 in the lowest tertile of
exercise had twice the risk of pancreatic cancer of those in the healthy weight range in the highest
tertile of physical activity, and the risk of pancreatic cancer was highest in obese individuals with
glucose abnormalities. These findings also suggest a role for insulin resistance and hyperinsulinaemia
in the relationship between physical activity and development of pancreatic cancer.
Neither of the studies of lung cancer or renal cancer included in Appendix F found any consistent
relationships with physical activity. Data from the Iowa WHS do however suggest that physical activity
may be protective against bladder cancer (which is also strongly associated with cigarette smoking in
women) (Tripathi, Folsom, & Anderson, 2002).
28
Of the three studies that have reported on the relationship between physical activity and overall
cancer mortality, the Iowa researchers reported "non-significant associations" (Kushi, Fee, Folsom,
Mink, Anderson, & Sellers, 1997), the NHS researchers reported a "modest reduced risk of cancer
mortality" and a non significant dose-response trend (Rockhill, Willett, Manson, Leitzmann, Stampfer,
Hunter, et al., 2001) and the SOF researchers found that increasing physical activity was associated
with decreased risk of cancer mortality (Gregg, Cauley, Stone, Thompson, Bauer, Cummings, & Esrud,
2003). It would appear therefore that the evidence relating to the potential of physical activity for the
prevention of cancers other than breast and colon cancer remains equivocal for women, and more
studies are required before definitive conclusions can be made.
In 2006, there will be an estimated 3,500 new cases of smoking related
cancer among women.
Because cancer mainly emerges later in life, the number of new cases of
cancer will increase in line with the strong growth of the population aged
50 years and over.
1 in 4 women are at risk of being diagnosed with cancer by age 75 years.
The average age of diagnosis in 2001 was 64 years.
1 in 11 women are at risk of dying of a malignant cancer before the age
of 75 years, and 1 in 6 are at risk of dying before the age of 85 years
AIHW, 2006
Physical Activity and Health – Updating the Evidence for Women
29
Physical Activity and Health in Mid-Age and Older Women
1.6 Mental Health
At the time the USSG report was written there was equivocal evidence about the role of physical
activity in the prevention and management of mental health problems (US Department of Health and
Human Services, 1996). The report cited four prospective longitudinal studies that examined the
relationships between physical activity and the primary prevention of depressive symptoms in the
general population.
In the NHANES I study, men and women who reported little or no physical activity and few depressive
symptoms at baseline were almost twice as likely to report depressive symptoms after eight years of
follow-up (Farmer, Locke, Moscicki, Dannenberg, Larson, & Radloff 1988). Similar results were found
in the Alameda County study in which 1799 men and women were followed for nine years (Camacho,
Roberts, Lazarus, Kaplan, & Cohen, 1991), and in the Harvard alumni study which followed 21,596
men for twenty years (Paffenbarger, Lee, & Leung, 1994). The fourth study however, found no
relationship between physical activity at baseline and psychiatrist-diagnosed depression in a cohort of
more than 1500 Bavarian men and women after five years of follow-up (Weyerer, 1992).
Since 1996, this area has received a great deal of research attention, with many reviews of the effects
of physical activity on constructs such as depression, anxiety, self-esteem, affect and mood, resilience
to stress and cognitive function. The Paluska & Schwenk review (2000) concluded that physical
activity had not been shown to prevent the onset of depression. In contrast, another review in the
same year found "convincing evidence" from cohort studies that maintenance of regular exercise can
reduce subsequent risk of depression (Fox, 2000). Philips, Kirnan & King (2003) also reviewed nine
cohort studies and found that most (eight) reported an inverse association between physical activity
and depression.
For the present review we found three more cohort studies which have explored the relationships
between physical activity and the primary prevention of mental health problems in women (see
Appendix G). The Melbourne Women's Midlife Project found that changes in physical activity were
positively associated with changes in well-being (Guthrie, Dudley, Dennerstein, & Hopper, 1997). A
later report from this study (not included in the table) found that life satisfaction during the
menopause transition was predicted by earlier exercise (Dennerstein, Dudley, Guthrie, & Barrett-
Connor, 2000).
30
Two papers from the Australian Longitudinal Study on Women's Health have also reported short term
prospective relationships between physical activity and mental health. The first reported that
increases in physical activity over three years were associated with improvements in emotional and
mental well-being among older women aged 70-78 years (Lee & Russell, 2003). The second reported
that increasing levels of physical activity in mid-age women (age 50-60 years) were associated with
decreases in depression scores, and that women who increased their physical activity by as little as
one hour per week over three years had reduced risk of poor mental health at five year follow-up
(Brown, Ford, Burton, Marshall, & Dobson, 2005). In contrast, the Rancho Bernado study found that
exercise did not protect against future depressed mood. The physical activity measure used in this
study was however very generic (Kritz-Silverstein, Barrett-Connor, & Corbeau, 2001).
1 in 5 adults will experience a mental illness at some time in
their life.
Depression and anxiety are the leading causes of disease burden
among women of working age.
Women aged 45-54 years report higher rates of psychological
distress than any other age group.
AIHW, 2006
Physical Activity and Health – Updating the Evidence for Women
31
Physical Activity and Health in Mid-Age and Older Women
Cognitive functioning
In recent years there has been growing interest in the relationships between physical activity and the
prevention of cognitive decline in older people. For this review we found six new cohort studies, and
all except one (Suutama & Ruoppila, 1998) reported associations between higher levels of physical
activity and reduced cognitive decline (see Appendix G).
In their 2001 study of women enrolled in the Study of Osteoporotic Fractures (SOF), Yaffe, Barnes,
Nevitt, Li-Yung & Covinsky (2001) found that the relative risk of cognitive decline decreased with
increasing physical activity in women aged 65 and older. Both moderate (eg playing golf once a week,
tennis twice a week or walking 1.6 km/day) and strenuous physical activity were associated with
reduced risk of cognitive decline after six to eight years, and the effects were most marked among
women aged 65-70 years. Similarly, researchers from northern Italy have reported that higher levels
of physical activity in a small cohort of 70-75 year-old women were associated with less decline in
cognitive function over 12 years (Pignatti, Rozzini, & Trabucchi, 2002).
Recent results from the NHS provide support for these findings. Both vigorous physical activity and
walking the equivalent of 1.5 hours per week at an easy pace (21-30 min/mile) were associated with
better cognitive performance after nine years (Weuve, Kang, Manson, Breteler, Ware, & Grodstein,
2004). After adjustment for multiple confounders, including chronic disease and functional limitations,
women in the highest quintile of total physical activity (>26 MET.hours per week, or about an hour a
day of brisk walking), were 20% less likely than women in the lowest quintile to experience cognitive
decline over six to eight years (Weuve et al., 2004).
The Canadian Study of Health and Ageing has also reported on associations between physical activity
and dementia and Alzheimer's disease. One study indicated that regular exercise was protective
against the development of vascular dementia in women aged older than 65 years (Hebert, Lindsay,
Werreault, Rockwood, Hill, & Dubois, 2000), but the measure of physical activity reported for this
study was very weak. However, in another analysis of data from the same study, which used a
composite measure of physical activity, the researchers found that physical activity was associated
with lower risks of cognitive impairment, Alzheimer's disease and dementia (Laurin, Verreault, Lindsay,
MacPherson, & Rockwood, 2001)
32
The results of these studies are sometimes seen to be controversial as there is a possibility of reverse
causation in all of them. In other words, a pre-existing cognitive impairment could have caused a
reduction in physical activity. However, both the SOF (Yaffe et al., 2001) and NHS (Weuve et al.,
2004) results were adjusted for a wide range of potential covariates and the relatively long follow-up
periods probably rule out this limitation. While the mechanism of the association between physical
activity and cognitive function is unclear, the NHS researchers propose that physical activity may
reduce cardiovascular risk factors and thereby ensure adequate vascular perfusion (Weuve et al.,
2004). Alternatively there may be a relationship between physical activity, insulin resistance and the
development of amyloid � plaques (which are a pathologic feature of Alzheimer disease) (Weuve et al.,
2004).
Although the changes in cognitive function scores reported in the NHS were small (Weuve et al.,
2004), subtle decreases in cognitive performance are a key predictor of dementia development. These
new findings therefore provide an important new focus for physical activity research. Approximately
11% of those aged 80 to 84 years, and 24% of those aged 85 years and over have dementia, and it
has been estimated that 65% of those over 80 have problems with reasoning and memory (Prime
Minister's Science, Engineering and Innovation Council, 2003). As higher levels of physical activity,
including walking, are associated with better cognitive functioning and less cognitive decline in older
women in these cohort studies, it will be interesting to see if physical activity can slow cognitive
impairment in randomised physical activity trials.
Dementia is the greatest single contributor to the burden of
disease due to disability at older ages, as well as to the cost of
care in residential aged care.
Dementia is more common in women than in men.
Although common in elderly people, dementia is NOT an inevitable
part of the ageing process.
AIHW, 2006
Physical Activity and Health – Updating the Evidence for Women
33
Physical Activity and Health in Mid-Age and Older Women
A note about secondary and tertiary prevention of mental health problems
A review of the secondary and tertiary prevention research (see page 3 for definitions) found that
physical activity may play a role in the management of mild to moderate mental health problems such
as depression and anxiety (Paluska & Schwenk, 2000). However, Lawlor and Hopker (2001)
undertook a detailed systematic review of the role of physical activity in the management of
depression, and found that no conclusion could be reached because of a "lack of good quality research
on clinical populations with adequate follow-up" (p 1). It is clear from this review that much of the
research is limited by small clinical samples, a focus on vigorous-intensity exercise, inadequate follow-
up beyond 12 months, a lack of assessor and/or participant blinding, and self reported outcome
measures.
In contrast, a 2003 review found that, although there was a need for more research with stronger
methodology, the literature was generally supportive of the beneficial effects of physical activity and
exercise on depression (Phillips, Kiernan, & King, 2003).
34
1.7 Musculoskeletal Problems
Osteoarthritis
The USSG report concluded that although there was no evidence that
physical activity causes osteoarthritis, injuries sustained during competitive
sports had been shown to increase the risk of development of
osteoarthritis (US Department of Health and Human Services, 1996).
For this review we identified five new reports from large cohort studies which have assessed
osteoarthritis as an outcome measure in women, and only one of these found a significant relationship
between physical activity and the risk of incident osteoarthritis (see Appendix H). None of the large
US women's cohort studies described earlier in this report has yet reported on osteoarthritis.
The Framingham study was established in 1948, with the aim of exploring risk factors for
cardiovascular disease. In 1983, when the average age of participants was 70.5 years, the
researchers began a sub-study with radiographic assessment of osteoarthritis. Using a measure of
physical activity based on usual physical activity during each hour of a typical day, the researchers
found the highest levels of physical activity were associated with increased risk of incident
osteoarthritis in this elderly sample of women who did not have osteoarthritis at baseline (Felsen,
Zhang, Hannan, Naimark, Weissman, Alibandi et al., 1997). Obesity, weight gain and (not) smoking
were also associated with increased risk of incident osteoarthritis.
As in previous studies, Felsen et al., (1997) found that obesity and weight gain were associated with
the development of osteoarthritis, particularly in women. While this may reflect increased joint loading
on hips and knees, the relationship between obesity and hand osteoarthritis suggests that this is not
the sole explanation. It is likely that systemic metabolic processes underlie the links between obesity
and osteoarthritis. Notwithstanding the mechanisms, the evidence suggests that about 3% of mid-
age women will develop radiological knee osteoarthritis every year, and confirms the importance of
avoiding weight gain at this life stage as an important preventive measure against development of
knee osteoarthritis (Hart, Doyle, & Spector, 1999).
The other studies did not confirm the Framingham findings. For example, in a subset of participants in
the Aerobics Centre Longitudinal Study (ACLS) which began in 1970, Cheng, Macera, Davis, Ainsworth,
Troped & Blair (2000) found that high levels of physical activity (running 20 miles per week or more)
were associated with increased risk of osteoarthritis, but only in men aged <50 (after adjustment for
BMI, smoking, alcohol and caffeine).
Physical Activity and Health – Updating the Evidence for Women
35
Physical Activity and Health in Mid-Age and Older Women
The lack of significant findings for women and older men may reflect the low numbers of women and
older participants in the high physical activity category (there were only 45 women aged over 50 years
in the high physical activity group, compared with 270 men; and only 166 younger women compared
with 733 men). Among younger women, body mass index and caffeine consumption, but not physical
activity, were associated with the development of osteoarthritis.
In a later study of the same cohort, the Cooper Clinic researchers created a physical activity joint
stress variable based on physical activity volume and estimated joint stress imposed by participation in
specific sports - values were highest for strenuous sports and weightlifting, and lowest for swimming
and stretching (Hootman, Macera, Helmick, & Blair, 2003). The joint stress physical activity score was
not associated with increased risk of osteoarthritis, and in the absence of joint injury, moderate
physical activity, such as walking, cycling and swimming, did not increase the risk of incident
osteoarthritis over a 12 year period. Older age, joint injury, previous joint surgery and high body mass
index were confirmed as independent risk factors for hip/knee osteoarthritis in men, but only age and
body mass index were independent risk factors in women (Hootman et al., 2003).
This research is important because it suggests that moderate-intensity physical activity is not
detrimental to joint health. The researchers argue that moderate types and amounts of physical
activity are imperative for developing and maintaining fitness and optimal body weight, and should not
be discouraged because of concern about osteoarthritis. Previous reports do, however, suggest that
men who play long term vigorous sports, such as various forms of football, and in particular those who
sustain a serious injury, do have increased risk of developing osteoarthritis and should therefore be
encouraged to adopt activities that place less load on the large weight bearing joints (Brukner & Brown
2005). To date there are no reports of long term participation in women's sport, such as netball, and
development of osteoarthritis.
The two remaining studies included in Appendix H did not find any association between physical
activity and osteoarthritis in women (Hart, Doyle & Spector, 1999; Seavey, Kurata, & Cohen, 2003).
However, the UK Chingford study included younger women (mean age 54.1 years) and confirmed
obesity as an important risk factor for osteoarthritis (Hart et al., 1999). In contrast, the Alameda
County study, which was established in 1965, found a protective effect of physical activity (measured
by frequency of participation in sports such as swimming, long walks, hunting/fishing, gardening and
physical exercises) on osteoarthritis in men, but not in women, after 20 years of follow-up (Seavey et
al., 2003)
36
Osteoarthritis is the most common form of arthritis and the
leading cause of activity limitations among older people.
Approximately 10% of Australian women have osteoarthritis.
64% of people with osteoarthritis are women.
The incidence of osteoarthritis increases with age and body mass
index.
AIHW, 2006
Physical Activity and Health – Updating the Evidence for Women
37
Physical Activity and Health in Mid-Age and Older Women
1.8 Injury
For this review we have chosen to focus on the outcome of fractures as an example
of injury. Although osteoporosis is now recognised as a health outcome in its own
right as a condition characterised by low mass and structural deterioration of bone
tissue, it leads to bone fragility and increased risk of fracture. It was, therefore,
conceptualised as a risk factor and excluded from this review.
It is well known that weight bearing physical activity and resistance training maintain
the normal structure and functional strength of bone, and increase bone mineral
density (BMD), thereby decreasing the risk of fracture (Drinkwater, 1993). However, risk of fracture is
complex and it is difficult to assess the independent role of physical activity in risk reduction as there
are complex interactions between physical activity and muscle strength, balance, BMD, use of
medications (including hormone replacement therapy), calcium intake, eyesight and falls, all of which
have been shown to have a role in the aetiology of fracture.
It is also likely that the skeletal effects of physical activity differ in younger and older women, with
evidence to suggest that exercise during periods of high growth (ie around the time of the adolescent
growth spurt) is associated with greater increases in bone density than occur at any other stage of the
life cycle (Bailey, 2000). This makes the evidence from prospective cohort studies of adults difficult to
interpret, as we cannot be sure that adults who report lower levels of physical activity now are not
protected against fracture by earlier efforts to get "bone in the bank" during childhood and
adolescence (Bailey, 2000). Notwithstanding, the USSG report concluded that there was promising
evidence to support the view that physical activity, including resistance training, is protective against
falling and fractures among the elderly, as a result of increased muscle strength and improved balance
(US Department of Health and Human Services, 1996).
For this review we found six new reports from cohort studies on the relationships between physical
activity and fracture in women (see Appendix I). The French OFELY (Os des Femmes de Lyon) study
tracked 672 healthy post-menopausal women for 5.3 years and found that low physical activity was
independently associated with increased risk of hip fracture, after adjustment for smoking, alcohol,
caffeine and calcium intake. (Albrand, Munoz, Sornay-Rendu, duBoeuf, & Delamas, 2003). Women
who sustained a fracture had significantly lower BMD and grip strength and were likely to have had a
previous history of fracture.
38
The US Study of Osteoporotic Fractures (SOF) followed a cohort of almost ten thousand women aged
over 65 years for 7.6 years (Gregg, Cauley, Seeley, Ensrud, & Bauer, 1998). Physical activity was
assessed using a modified version of the Harvard Alumni questionnaire. The researchers found that
each increasing quintile of physical activity was associated with reduced relative risk of hip fracture;
with the greatest risk reduction in women who reported participation in aerobics, tennis or weight
training, or at least two hours of moderate/vigorous physical activity per week. There was also a
significant reduction of hip fracture in women who reported ten or more hours of vigorous household
chores each week. In this study physical activity was not associated with wrist or vertebral fracture.
In contrast, data from the Blue Mountains Eye Study (which was established to explore risk factors for
eye disease, and therefore has an interest in fracture through the links between visual acuity and
falls), found that women who reported doing no vigorous physical activity had a reduced risk of wrist
fracture (Ivers, Cumming, Mitchell, & Peduto, 2002). These somewhat surprising data confirm
previous data from the SOF that suggest that wrist fracture occurs in women who are active and
healthy and presumably participating in the type of physical activity that would predispose them to
falling.
The remaining studies in Appendix I focus on hip fracture. The most comprehensive data are from the
NHS, which found that, in their cohort of more than 61,000 post-menopausal women, risk of hip
fracture declined by 6% for every hour per week of walking at average pace (Feskanich, Willett, &
Colditz, 2002). The effects were seen in both lean and heavy women, but the heavier women had
lower risk of fracture. This is hypothesised to reflect both the increased BMD which is associated with
higher body mass index, and potential protective effects of adipose tissue around the hips (Chaperlat,
Bauer, Nevitt, Stone, & Cummings, 2003).
The NHS researchers estimated that if all the women had exercised at 9 MET.hours per week (2.3
hours of brisk walking) or more, 23% of hip fractures could have been prevented (Feskanich et al.,
2002). If all women were active for 24 MET.hours per week (6 hours per week, or an hour on most
days) there would be a 42% reduction in risk of hip fracture. Importantly, women who only walked (ie
reported no other form of activity) for 4 hours a week or more, had a 40% decreased risk fracture,
and even those who reported standing at work for 10 hours or more each week had a 28-46%
reduction in risk. This evidence suggests that occupations such as nursing and teaching that involve
standing (rather than sitting) at work may decrease the risk of fracture, independent of body weight
and time spent in leisure activities (Feskanich et al., 2002). The NHS researchers also reported that
active women not taking oestrogen supplements had similar protection against hip fracture to that
provided by hormone use (Feskanich et al., 2002). The Danish Nurse Cohort Study also found that
hormone replacement therapy did not modify the beneficial effect of activity on hip fracture risk
(Hundrup, Ekholm, Hoidrup, Davidson, & Obel, 2005; see Appendix I).
Physical Activity and Health – Updating the Evidence for Women
39
Physical Activity and Health in Mid-Age and Older Women
1 in 11 people aged 85 years or over were admitted to hospital
with injury following a fall in 2003-4.
Injury-related hospitalizations are half as long again for women as
for men.
Unintentional falls are the most common cause of injury among
women.
In the last ten years, injury death rates have been steadily
increasing for persons aged over 85 years.
Falls account for one fifth of fatal injuries in Australia.
AIHW, 2006
40
1.9 Reproductive Health
Although this area is not identified as a national public health priority, consideration of the effects of
physical activity on gynecological and obstetric health are included in this report because these issues
are of clear interest for women's health. Moreover, while not directly relevant to many older women,
research into the impact of physical activity on the menstrual cycle has attracted significant interest,
especially in light of the so called female athlete triad of amenorrhea, low body fat and eating
disorders. At the "other end" of the reproductive life cycle, there has been some research into the
effects of physical activity on the timing of and symptoms associated with menopause.
For this review, we found that very few of the large population-based women's cohort studies have
explored any reproductive health issues. Most research has been conducted with relatively small self-
selected non-representative groups of women (for example highly trained elite athletes), often with
poor measures of physical activity, and difficulties with outcome measures such as reporting the exact
timing of menopause.
In terms of menstrual symptoms, exercise scientists have focused their interest on training-related
amenorrhea which is caused by complex interactions between training induced changes to female
reproductive hormones and fat metabolism, and hypothalamic control of the menstrual cycle. Very
high levels of training with reduced levels of body fat (such as is often seen in ballet dancers and
endurance athletes) can lead to either shortened or lengthened menstrual cycles and eventually to
complete cessation of menstrual periods. There has also been considerable interest in the relationship
between physical activity and dysmenorrhea (painful periods) and several randomised trials (mostly
with college students) have shown a protective effect in terms of decreased symptoms with a program
of training (Golomb, Solidum, & Warren, 1998).
It is, however, difficult to isolate exercise-related improvements in mood from true improvements in
symptoms, and there are significant methodological problems in most of these studies. None of the
large women's cohort studies has reported on the relationship between physical activity and menstrual
symptoms. Sternfeld, Jacobs, Quesenberry et al (2002) reported on the results of two smaller studies,
both of which found a positive association between vigorous physical activity and cycle length. These
findings lend some support to the hypothesis that vigorous physical activity can increase the length of
the menstrual cycle (Sternfeld et al., 2000).
Physical Activity and Health – Updating the Evidence for Women
41
Physical Activity and Health in Mid-Age and Older Women
The Melbourne Women's Midlife Health Project has tracked approximately 400 women through the
menopause transition (Guthrie, Dennerstein, Taffe, Lehert, & Burger, 2005). The researchers
found that low exercise levels are significantly associated with increased reporting of hot flushes, and
that women who never report hot flushes are more likely to be high exercisers. This relationship has
not been consistently shown in previous studies, and there is a clear need for more cohort studies to
report on relationships between physical activity and both menstrual and menopausal symptoms.
Again, while not directly relevant to mid-age and older women, the issue of exercise and pregnancy
is included here, in the interests of mid-age and older women who have daughters who are pregnant
or planning to become pregnant. There has been considerable debate in recent years about the
impact of physical activity on health outcomes for both mother and baby if expectant women exercise
during pregnancy (Sports Medicine Australia, 2002). In relation to exercise and pregnancy, most
research has focused on pre-term birth, labour-related complications and birth outcomes such as birth
weight. In 2002, a statement from Sports Medicine Australia which was based on a review of the
current literature, found that healthy pregnant women could begin or maintain moderate intensity
aerobic exercise programs with little fear of adverse effects on their
unborn foetus, and that concerns about the potential ill–effects of
exercise during pregnancy, such as hyperthermia, shortened
gestational age and decreased birth weight were not supported by
the most recent review papers (Brown, 2002; Sports Medicine
Australia, 2002).
For this review we found two recent studies which followed prenatal patients throughout pregnancy
and recorded physical activity during pregnancy and length of gestation (Hatch, Levin, Shu, & Susser,
1999; Misra, Strobino, Stashinko, Nagey & Nandy, 1998) (see Appendix J). There was no clear
association in either study between moderate physical activity and duration of gestation. In the
Pennsylvania and New York study, the researchers reported that heavier levels of exercise, especially
among previously conditioned women, appeared to significantly reduce the risk of pre-term birth
(Hatch et al., 1998).
Among the few women who delivered post-term, conditioned heavy exercisers delivered more quickly
than non-exercisers (Hatch et al., 1998). In contrast, the Maryland study found that the odds of pre-
term delivery were increased in women who reported stair climbing and purposive walking (Misra et
al., 1998).
42
1.10 Discussion
The evidence included in Part One of this report supports the notion that there
is an inverse dose dependent relationship between physical activity and
cardiovascular disease, some cancers, diabetes, mental health problems, and
musculoskeletal problems in women. Importantly, the results of some these
studies, which followed women from mid-age, found benefits for women who
became active later in life, even if they had been sedentary for a long time
(Hu, 2000).
In 1996, the associations between inactivity and health problems appeared to be stronger for
cardiovascular disease and type 2 diabetes, (which have intermediate metabolic and physiological risk
factors such as blood lipids, blood pressure etc that were also recognised as being independently
affected by activity). More recent studies have strengthened the evidence relating physical activity to
the prevention of some forms of cancer. Links between physical activity and fat metabolism,
hormones, growth factors and immune function may also underlie these relationships. There is also
new evidence relating to physical activity and mental health problems. Most, but not all of this
evidence suggests an inverse association between physical activity and the development of depression,
and there is growing evidence of a role for physical activity in the prevention of cognitive decline in
older women. For some musculoskeletal problems (eg osteoarthritis and fractures), the evidence
suggests that there are clear health benefits of regular physical activity for women.
From the evidence reviewed here there is no indication that physical activity can be harmful for
women's health at the population level. Although injury (from participation in vigorous competitive
sport) is implicated in the aetiology of osteoarthritis in men, none of the recent studies of physical
activity and osteoarthritis have confirmed this association in women.
The evidence presented in this review provides a strong rationale for greater investment in the
promotion of physical activity as a strategy for the primary prevention of a range of chronic health
problems in women.
Physical Activity and Health – Updating the Evidence for Women
43
Physical Activity and Health in Mid-Age and Older Women
KEY ISSUES
There is an inverse dose dependent relationship between physical
activity and cardiovascular disease, some cancers, diabetes,
mental health problems, and musculoskeletal problems in women.
There are benefits for women who become active later in life, even
if they have been sedentary for a long time.
There is no indication that physical activity can be harmful for
women's health at the population level.
There is strong evidence to promote physical activity as a strategy
for the primary prevention of a range of chronic health problems in
women.
44
How Much Activity for Health Benefits?
45
Physical Activity and Health in Mid-Age and Older Women
2. HOW MUCH ACTIVITY FOR HEALTH BENEFIT IN WOMEN?
2.1 Introduction
In 1995 the US Centers for Disease Control and the American College of Sports Medicine
recommendation for the dose of physical activity required for health benefit was for 30 minutes of
moderate intensity physical activity on most days of the week (Pate et al., 1995). The Australian
National Physical Activity Guidelines for Adults also recommend at least 30 minutes of moderate
intensity physical activity on most, preferably all, days of the week to enhance your health
(Commonwealth Department of Health and Aged Care, 1999). Vigorous activity is recommended for
those who are able, and wish, to achieve greater health and fitness benefits, and should be carried out
for a minimum of 30 minutes, three to four days a week
46
However in light of the growing obesity problem, in 2005 the US Department of Health and Human
Services and the Department of Agriculture endorsed the 30 minutes of physical activity
recommendation, but called for a minimum of 60 minutes/day of moderate intensity physical activity
for the prevention of weight gain, and 90 minutes/day for the maintenance of weight loss in formerly
obese individuals (US Department of Health and Human Services and the Department of Agriculture,
2005).
Since then, two recent randomised trials have shown that the existing national guidelines are sufficient
for weight loss in overweight people following a low-calorie diet (Jakicic, Marcus, Gallagher, Napolitano
& Lang, 2003) and for the prevention of weight gain in the absence of dietary change (Slentz, Duscha,
Johnson, Ketchum, Aiken, Samsa, et al., 2004). Recently published data from the Australian
Longitudinal Study on Women's Health also support the notion that 30 minutes of moderate intensity
physical activity can prevent weight gain in mid-age women (Brown, Williams, Ford, Ball, & Dobson,
2005).
Medical practitioners usually prescribe a specific dose of medication for management of health
problems. This dose typically comprises concentration (eg 50, 100mg), frequency (eg three times per
day), and duration (eg for 7 days) of use. Although the terms are not exactly congruous, the dose of
physical activity required for prevention of a health problem can also be described in terms of
� intensity (eg light, moderate, vigorous)
� duration (e.g. the length of each session) and
� frequency (eg number of times per week).
It is difficult however to consider each of these independently, as the overall dose or volume of
physical activity is a combination of intensity, duration and frequency, which together contribute to
the overall energy expenditure of the activity. The question of whether different methods of
achieving a certain energy expenditure or physical activity dose (eg by walking for a long time, or
running for a shorter period) contribute to differences in health outcomes, is considered below.
How Much Activity for Health Benefits?
47
Physical Activity and Health in Mid-Age and Older Women
2.2 Intensity
Although both the USSG report (US Department of Health and Human Services, 1996) and the
Australian Guidelines (Commonwealth Department of Health and Aged Care, 1999) suggest that
vigorous physical activity will confer greater health benefits than moderate physical activity, it is not
clear if this is the case for mid-age and older women. Almost all the large cohort studies use
measures of energy expenditure for physical activity, and it is now evident that the risk of several
health outcomes decreases as volume of physical activity increases. Since vigorous physical activity
requires higher energy expenditure, it is sometimes assumed that those who report higher volumes of
physical activity are engaging in vigorous activity, and this assumption underpins many public health
recommendations for physical activity.
Data from three of the large US women's cohort studies now suggest however, that energy
expenditure from walking can confer similar benefits, in terms of reducing the risk of several health
problems, to those seen with vigorous physical activity. The Nurses Health Study for example has
reported that, compared with sedentary women, those who walk briskly for three hours/week or
exercise more vigorously for 1.5 hours/week, have a 30-40% reduction in risk of myocardial infarction
(Manson et al., 1999). The Women's Health Initiative (WHI) has shown that walking briskly for 2.5
hours per week is associated with a 30% reduction in cardiovascular events, even after only 3.2 years,
and that more vigorous physical activity is associated with similar risk reduction, after adjusting for
total energy expenditure (Manson et al., 2002). Similarly, the Women's Health Study has reported that
health professionals who walked for just one hour per week had a 50% reduction in risk of CHD, even
if they reported no vigorous physical activity (Lee et al., 2001).
This raises the issue of whether light activities might also be associated with health benefits. For
example, the NHS has reported significantly reduced risk of diabetes with only light household work
(Hu et al., 2003), and the Australian Longitudinal Study on Women's Health found that just one hour a
week of physical activity was associated with decreased risk of depressive symptoms (Brown et al.,
2005). In the Women's Health Study, even in women who had additional risk factors (ie were
overweight, had high cholesterol, or were smokers), light to moderate physical activity was associated
with reduced risk of many health problems (Lee et al., 2001).
48
One problem with the evidence relating to intensity is that in most studies participants are asked to
report time spent in moderate and vigorous physical activity, and it is highly likely that perceptions of
intensity differ markedly with age and fitness. For example, swimming at 4 METs (which is considered
to be moderate intensity) would require 33% of capacity for a fit young woman with a capacity to
swim at 12 METs, and would be reported as moderate. The same speed of swimming would require
66% of capacity for a fit older woman with a capacity to swim at 6 METs, who might therefore report
this activity as vigorous. The issue of recalling and reporting the intensity of activities is particularly
pertinent among women who typically do not participate to the same extent as men in structured or
organised sport/exercise. This is because time spent in less 'structured' moderate-intensity activities is
less reliably reported (Brown, Trost, Bauman, Mummery and Owen, 2004) and the intensity of these
activities is more difficult to assess (Ainsworth, 2000).
Notwithstanding the measurement problems, there is now accumulating evidence that for mid-age and
older women, there is little additional benefit of vigorous activity, over and above that obtained from
the same level of energy expenditure from moderate-intensity activity. This does not mean that
vigorous physical activity should be discouraged for those who wish to do it; but rather that it is not
necessary for mid-age and older women to be vigorously active to derive health benefits.
How Much Activity for Health Benefits?
49
Physical Activity and Health in Mid-Age and Older Women
2.3 Duration
The question of whether several short (eg 10 minute) sessions of physical activity
are as effective in influencing health outcomes as one longer (eg 30 minutes)
session was explored in a review by Hardman (2001). As few of the cohort studies
have collected information about the duration of individual sessions of physical
activity, most of the evidence comes from small randomised controlled trials with
biological (eg fitness, triglycerides etc) outcomes.
In terms of improving cardiorespiratory fitness, Hardman (2001) found that there was some (limited)
evidence to support the view that several short sessions per day were as effective as one longer or
continuous session, and for biological markers such as triglycerides, two short sessions of
moderate/hard exercise were as effective as a single session of the same duration. As none of the
large women's cohort studies has explored the relationship between shorter bouts of physical activity
and health outcomes, it is not clear whether women should accumulate their daily physical activity in
sessions shorter than 30 minutes a day. Further analysis of data from the large cohort studies is
required before definitive statements on the minimum duration of physical activity sessions for health
benefits in women can be made.
50
2.4 Frequency
Lack of time is a common reason for not participating in physical activity
(Booth, Bauman, Owen, & Gore, 1997), especially among women who
typically face the juggling time issues associated with paid and unpaid
work (Eyler, Matson-Koffman, Vest, Evenson, Sanderson, Thompson et al.,
2002). There may be, therefore, an advantage for women to compress
their physical activity into one or two sessions each week, rather than to
be active on most, if not all, days of the week. The health effects of this
pattern of physical activity have not been widely researched.
Issues of frequency of physical activity have been explored in detail by I-Min Lee, who introduced the
concept of the weekend warrior to describe patterns of physical activity seen typically in men, who
might participate in organised sport, such as golf or tennis, only on weekends (Lee, Sesso, Oguma, &
Paffenbarger, 2004). Using data from the male participants in the Harvard alumni study, Lee et al.,
(2004) concluded that a physical activity pattern which utilises 1000 kcal/week or more was required
for health benefit, and that this could be accumulated in only one to two sessions per week, provided
no other risk factors (eg smoking, alcohol, diet etc) for ill-health were present. For those with
additional risk factors, health benefits were only observed in those who were active three or more
times weekly (Lee et al., 2004). There are not yet any comparable data from the large US women's
cohort studies, but there is no reason to believe that similar results to those reported for men (Lee et
al. 1994), would not also be seen in women.
How Much Activity for Health Benefits?
51
Physical Activity and Health in Mid-Age and Older Women
2.5 Total Time and Volume of Physical Activity: Duration, Frequency and Intensity
In Australia the National Physical Activity Guidelines for Adults recommend at least 30 minutes of
moderate intensity physical activity on most, preferably all, days of the week (Commonwealth
Department of Health and Aged Care, 1999). This study has interpreted this statement to mean a
minimum of 5 sessions of 30 minutes per week, or 150 minutes of moderate intensity physical activity
each week. If we assume an average moderate intensity physical activity to be 4 METs, this equates
with 600 MET.mins per week. In the US, values are typically reported in MET.hours per week, so the
equivalent target is 10 MET.hours per week.
From the evidence presented above, it is clear that achieving 150 minutes, or 600 MET.mins, of
physical activity is associated with health benefits across a wide range of health outcomes. However,
for some health problems, such as breast and colon cancer, it may be necessary to accumulate greater
amounts of physical activity (say 1200 MET.mins per week). This need not necessarily be more
vigorous physical activity, but could be achieved, for example, by walking for an hour a day, five days
a week, or by jogging for 30 minutes a day at twice the intensity of walking.
For optimal bone health it may also be true that higher intensity physical activity has a more beneficial
effect on bone mineral density and therefore on risk of fracture. However, for elderly women,
vigorous physical activity may be associated with increased risk of falls-related fracture, so activities
that improve balance and flexibility are important for reducing the risk of falling. At the same time,
weight bearing and resistance training will increase muscle strength and mass, and may increase BMD,
leading to reduced risk of fracture (Feskanich et al., 2002).
Notwithstanding this, it is also becoming clear that there can be significant health benefits in some
areas (eg prevention of cardiovascular problems, diabetes, mental health problems and osteoarthritis)
for women who walk briskly for as little as one hour per week (ie 60 minutes, or 240 MET.mins or 4
MET.hours per week). While more physical activity will confer greater benefit, this is good news for
women who are, for whatever reason, unable to achieve the recommended 'dose' of 150 minutes each
week.
52
2.6 Discussion
It is clear that there is a need for more research into the dose-response issues relating to physical
activity and health to clarify the individual contributions of intensity, frequency, duration of physical
activity to different health outcomes. Several groups of US researchers are now conducting
randomised controlled trials which are exploring the effect of different combinations of duration,
frequency and intensity on health outcomes in women (e.g. Morss, Jordan, Skinner et al., 2004; Dunn,
Trivedi, & O'Neal, 2001). A major challenge with these studies is to find representative samples of
women who will comply with the different physical activity protocols for long enough for the health
outcomes to be explored.
What is absolutely clear from this review is that the so called Rose principle of improving population
health holds true in terms of physical activity and health (Rose, 1992). If a large segment of
population could be persuaded to adopt modest improvements in physical activity – even 15-30
minutes per day, every day – the overall reduction in disease burden would be greater than if a
modest segment adopted larger changes. It is also clear from the evidence reviewed here that getting
women who are currently sedentary to 'take' a small daily dose of physical activity would result in
much greater health outcomes than getting those who are already active to double their dose of
physical activity.
In light of the health benefits of being more active in mid-age, public health policy should now focus
on getting the most sedentary women to become more active. Even 15 minutes of daily moderate
intensity activity is associated with some health benefits. Mid-age and older women who are already
meeting activity guidelines should be encouraged to maintain this level of activity for as long as
possible as they age. The magnitude of this challenge is outlined using data from the ALSWH in the
next section of this report.
How Much Activity for Health Benefits?
53
Physical Activity and Health in Mid-Age and Older Women
KEY ISSUES
Achieving 150 minutes of physical activity per week is associated with
significant health benefits across a wide range of health outcomes.
Women who walk briskly for as little as one hour per week can achieve
significant health benefits (eg prevention of cardiovascular disease,
diabetes, and poor mental health).
Greater amounts of physical activity may be required for other health
benefits (eg prevention of breast and colon cancer).
Women need not do vigorous physical activity to derive health benefits.
If a large segment of the population made modest improvements in
physical activity - even 15-30 minutes/day - the overall reduction in
disease burden would be greater than if a small segment made larger
improvements.
More research is needed to clarify the contributions of intensity,
frequency and duration of physical activity to different health outcomes.
54
How Active are Australian Women?
55
Physical Activity and Health in Mid-Age and Older Women
3. HOW ACTIVE ARE AUSTRALIAN MID-AGE AND OLDERWOMEN?
3.1 Introduction
This section will consider
� The prevalence and patterns of physical activity and inactivity among mid-age and older
participants in the Australian Longitudinal Study on Women's Health (ALSWH),
� Trends over time in physical activity,
� Factors associated with changes in physical activity in consecutive surveys.
56
3.2 The Australian Longitudinal Study on Women's Health – Background and Details of the Surveys
The information in this section of the report is based on data from
the Australian Longitudinal Study on Women's Health (ALSWH). The
ASLWH – widely known as Women's Health Australia - is a
longitudinal population-based survey, funded by the Australian
Department of Health and Ageing. The project began in 1996 when
three large, national cohorts representing three generations of
Australian women were established (Brown, Bryson, Byles, Dobson,
Lee, Mishra, & Schofield, 1998).
� The younger women were aged 18-23 years when first recruited in 1996 (N=14,247). In 2007,
they were aged 28-34 years, the peak years for relationship formation, childbearing, and
establishing adult health habits (eg physical activity, diet) and paid and unpaid work patterns.
� The mid-age women were initially aged 45-50 years in 1996 (N=13,716). In 2007, they were
aged 55-61 years, and most have now experienced menopause, as well as changes in household
structure and family care giving. Some are now contemplating retirement and are adopting new
health behaviours in preparation for a healthy old age. Others are showing early signs of age-
related physical decline.
� The older women were aged 70-75 years when first recruited in 1996 (N=12,432). In 2007, they
are now aged 81-86 years and facing the physical, emotional and social challenges of old age.
This report is based on data from the mid-age and older cohorts.
How Active are Australian Women?
57
Physical Activity and Health in Mid-Age and Older Women
Features of the ALSWH study design
� Women were randomly selected from the Medicare Australia database and invited to participate in
the longitudinal study in 1996.
� Women in rural and remote areas of Australia were intentionally over-sampled to ensure adequate
numbers for statistical analysis, and to capture the heterogeneity of health patterns among women
living outside the metropolitan areas.
� ALSWH uses a mail survey methodology, with some telephone follow-up.
� Following the initial surveys in 1996, women in the three age cohorts have been surveyed
sequentially, one cohort per year, on a rolling basis since 1998. The notation used in this report
for the surveys, the years the surveys were conducted, and the ages and numbers of women at
each survey are shown in Figure 3.1.
What is included in the surveys?
The study was initially designed to explore factors that influence the health of women who are broadly
representative of the Australian population. There is a strong focus on the social determinants of
health and on the aetiology of chronic health problems in mid-age and older women. There are
questions in every survey on
� Physical and emotional health (including well-being, major diagnoses, symptoms)
� Use of health services (general practitioner, specialist and other visits; access; satisfaction)
� Health behaviours and risk factors (physical activity, diet, smoking, alcohol, drug use, BMI)
� Time use (including paid and unpaid work, family roles, and leisure)
� Socio-demographic factors (location, education, employment, family composition)
� Life stages and key events (such as childbirth, divorce, widowhood).
The project provides a valuable opportunity to examine associations over time between aspects of
women’s lives and their physical and emotional health. It provides an evidence base to the Australian
Department of Health and Ageing, as well as other Australian and State/Territory Departments, for the
development and evaluation of policy and practice in many areas of service delivery that affect
women. An overview of the study and investigators, copies of the questionnaires, and abstracts of
publications and presentations can be located on the website www.alswh.org.au.
58
1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Young
�
Y1 18-23 14,247
�
Y2 22-27 9,688
�
Y3 25-30 9,081
�
Y4 28-33
9,143*
Mid-age
�
M1 45-50 13,716
�
M2 47-52 12,338
�
M3 50-55 11,229
�
M4 53-58 10,906
Older
�
O1 70-75 12,432
�
O2 73-78 10,434
�
03 76-81 8,647
�
O4 79-84 7,153
S1 S2 S3 S4
*survey incomplete Study will extend to 2016
Figure 3.1 Timeline and ages of the women at each of the ALSWH surveys.
How Active are Australian Women?
59
Physical Activity and Health in Mid-Age and Older Women
Response rates
Response rates to Survey 1 (1996) cannot be specified exactly as some women selected for the
sample may not have received the invitation to participate. For example, deaths or changes of
address may not have been notified to the Health Insurance Commission (now Medicare Australia). It
is estimated that 53-56% of the mid-age women and 37-40% of the older women agreed to
participate in the longitudinal study.
The project has retained a very high proportion of the original participants. In 1998, 91% of the
13,716 mid-age women who responded to Survey 1 also responded to Survey 2, and 84% responded
to Survey 3 in 2001 and Survey 4 in 2004. Almost three quarters (72%, N=9,861) of the women in
this cohort have responded to all four surveys, and a further 13% have completed three and 9% have
completed two of the four surveys. The major reasons for non-response were that the research team
was unable to contact the women (6%, 7% and 8% of eligible women at Survey 1, Survey 2 and
Survey 3 respectively) and non-return of questionnaires by women who could be contacted (2%, 8%
and 7% of eligible women at Survey 2, Survey 3 and Survey 4). The women who could not be
contacted were more likely to be separated, divorced or widowed. Change of name and address, and
failure to register these with the electoral commission, makes the tracking of these women difficult.
Comparisons with Census data from 1996 and 2001 show that the mid-age respondents at Survey 1
(1996) and Survey 3 (2001) were broadly representative of the general population of women of the
same age, but that there was some over-representation of women with tertiary education and under-
representation of immigrant women of non-English speaking background and of women who were
separated or divorced at both surveys.
Of the 12,432 older women who responded to Survey 1, 90% responded to Survey 2 in 1999, 85% to
Survey 3 in 2002, and 84% to Survey 4 in 2005. Fifty four percent of the older women have
completed all four surveys, 17% have completed three surveys and a further 16% have completed
two. In this cohort, the major reason for non-response was non-return of the questionnaire (4% of
eligible women at Survey 2 and 8% at Survey 3). These and other non-respondent women tended to
report poorer self-rated health at Survey 1 than respondents to subsequent surveys, and, not
unexpectedly in this age group, discontinuation was commonly due to death or frailty. Comparisons of
the demographic characteristics of the older respondents at Survey 1 (1996) and Survey 3 (2002) with
those of women of the same age in the Census in 1996 and in 2001 showed few differences. There
was some under-representation of women from non-English speaking countries in the ALSWH sample
at both surveys. The high level of missing data in the Census makes comparisons difficult for marital
status and educational qualifications.
For this report, data are from the mid-age cohort at M1 (1996), M2 (1998), M3 (2001) and M4 (2004)
and from the older cohort at O1 (1996), O2 (1999), O3 (2002) and O4 (2005).
60
Area of residence
Throughout this report, area of residence is classified according to the Rural, Remote and Metropolitan
Areas classification scheme (Department of Human Services and Health, 1994). The classification uses
postcode to derive seven categories (two metropolitan, three rural and two remote areas) that are
based primarily on population numbers and an index of remoteness. All prevalence and incidence
estimates in this report are weighted to correct for the intentional over-sampling of women from rural
and remote areas.
Measurement of physical activity
Women in all three cohorts have answered questions about physical activity in all surveys. At Survey 1
in 1996, the questions used were those developed by the National Heart Foundation for the National
Risk Factor Prevalence Surveys in 1980, 1983, and 1989 (National Heart Foundation, 1989). The two
questions asked how many times in a normal week women engaged in vigorous exercise (eg aerobics,
jogging) or less vigorous exercise (eg walking, swimming) lasting for 20 minutes or more. Responses
were used to derive a physical activity score based on frequency of participation in vigorous (7.5
METs) and less vigorous (4 METs) physical activity lasting at least 20 minutes. [PA score=�{frequency
* 20mins * 4 (less vigorous) + frequency * 20mins * 7.5 (vigorous)}]. MET.mins are units of energy
expenditure – 600 MET.mins is equivalent to 150 minutes of moderate intensity (4 METs) physical
activity per week (Brown, Mishra, Lee, & Bauman, 2000).
For all surveys since the first in 1996, physical activity has been assessed using
questions based on those developed for the evaluation of the national Active
Australia campaign in 1997, and for national monitoring of physical activity in
Australia (Armstrong, Bauman, & Davies, 2000). The questions ask about the frequency and total
duration of walking (for recreation or transport), and of vigorous (eg aerobics, jogging) and moderate
intensity activity (eg swimming, golf) in the last week. The items used in all surveys since 1999 have
been shown to have acceptable reliability and validity for population measurement of physical activity
(Bauman & Merom, 2002; Brown, Trost, Bauman, Mummery, & Owen, 2004). (Note that the physical
activity data from the second survey of the mid-age women are not directly comparable with those of
subsequent surveys because gardening was included as an example of moderate activity; this may
have inflated the estimates of activity in that survey). For all the analyses reported here, a physical
activity score was derived from reported duration of time spent in each form of physical activity during
the last week [� {(walking mins * 3.0) + (moderate mins * 4.0) + (vigorous mins * 7.5)} MET.mins]
(Brown & Bauman, 2000). As the distribution of physical activity data is heavily skewed, continuous
data are presented as medians and inter-quartile ranges (IQR).
How Active are Australian Women?
61
Physical Activity and Health in Mid-Age and Older Women
3.3 Prevalence and Patterns of Physical Activity
The National Physical Activity Guidelines suggest that, for health benefit, all Australians should
accumulate at least 30 minutes of at least moderate intensity physical activity on most, if not all, days
of the week (Commonwealth Department of Health and Aged Care, 1999). The ALSWH researchers
use a cut-off of 600 MET.mins per week (30 minutes * 5 sessions * 4 METs) to define whether women
are active – that is, whether they are accumulating sufficient physical activity for health benefit. Data
from Survey 1 are not included in this section as different physical activity questions were asked in
Survey 1.
The proportions of mid-age and older women in each of five physical activity categories (none: < 40;
very low: 40 - <300; low: 300 - <600; moderate: 600 - < 1200; high: � 1200 MET.mins/week) are
shown for Surveys 2, 3 and 4 in Figure 3.2.
In the mid-age cohort, the proportions categorised as being moderate and high active (ie those
meeting or exceeding the National Physical Activity Guidelines, defined here as active) increased
markedly from M3 (moderate 20.3%; high 24.5%) to M4 (moderate 22.8%; high 31.4%), while the
proportions in the none, very low, and low categories (defined here as inactive) decreased. The
overall prevalence of being active increased by 9.4% (from 44.8% to 54.2%) between these two
surveys.
This remarkable increase in physical activity among the mid-age cohort between Survey 3 and Survey
4 resulted in the proportion categorised as active in this cohort at Survey 4 (in 2004 when they were
53–58 years old) being the same (54.2%) as that reported at Y3 for the younger cohort (54.6%) in
2003 when they were 25–31 years old. These data counter the much cited statistic that population
levels of physical activity decline with age (Armstrong, et al., 2000). This increase was underpinned by
increases in walking, which were observed in this cohort between M2 (1998) and M3 (2001) and
continued at M4 (2004). The increase in walking is consistent for women living in urban areas, large
and small rural centres and in other rural and remote locations, and probably reflects either an age or
cohort effect of changing life circumstances of the mid-age women, which may be allowing some of
them more time to walk (see below for further discussion of this point).
Among the older cohort there were increases in the proportions of women reporting no activity from
O2 (31.3%) to O3 (39.7%) and from O3 to O4, so that by O4, 44.4% of this cohort were in this
sedentary category. There was also a marked decrease in the proportion in the low activity group
between O2 (20.9%) and O3 (12.1%). The prevalence of being active in this group was fairly
constant between O2 (33.8%) and O3 (33%), but fell by 3% between O3 and O4 (29.9%).
62
All Australians should accumulate 30 minutes of at least
moderate-intensity physical activity on most, if not all,
days of the week.
Commonwealth of Australia, 1999
54% of ALSWH mid-age women (53-58 years) met this guideline in 2004.
30% of ALSWH older women (79-84 years) met this guideline in 2005.
While these data suggest that overall levels of physical activity in this cohort are declining, it was
apparent that most of those who managed to remain active from O2 to O4 were still reporting similar
amounts of time in physical activity in consecutive surveys. The overall decline was attributable to the
increasing numbers of women in this cohort who were in the none category at O3 and O4. As the
older women were aged 79-84 years at O4, it would not be surprising to find that increasing health
problems underpin this decline (see below for further discussion of this point).
How Active are Australian Women?
63
Physical Activity and Health in Mid-Age and Older Women
Note that this figure is based on data from ALL women who answered the physical activity questions at each survey, and that the inclusion of gardening in the examples of moderate activity at M2 means that these M2 data are not directly comparable with those from the subsequent M3 and M4 surveys.
Figure 3.2 Proportions of women in each physical activity category in subsequent surveys at M2 (N=11,226), M3 (N=10,671), and M4 (N=10,163); and at O2 (N=9,123), O3 (N=8,052) and O4 (N=6,523).
0%
20%
40%
60%
80%
100%
M2 M3 M4 O2 O3 O4
none very low low moderate high
Mid-age Older
64
Patterns of physical activity
At M3 and M4, and at O2 and O3, the contributions of walking, moderate and vigorous activity to total
physical activity differed slightly for each cohort. For the mid-age cohort the most common pattern of
activity at M3 was only walking, (reported by 43.5%), with a smaller proportion reporting a
combination of all three types of activity (35.5%). Few women reported only moderate (3.4%) or
vigorous (1.4%) activity. Those who reported a combination of walking and other activities reported
higher total physical activity time [M3 median 300 (180-480)] than those who reported only walking
[M3 median 120 (60-240)], or only moderate (M3 median 120 (60-240)] or vigorous activity [M3
median 135 (70-240)]. Almost 16% of the mid-age women reported no walking, moderate or vigorous
activity, but half of these did report some activity associated with house and yard work. Data on
house and yard work are not included in these physical activity estimates because there are questions
about the intensity of these activities (Brown, Trost, Ringuet, & Jenkins, 2001) and about the reliability
of the time estimates that are reported (Ainsworth, 2000)
At M4 the proportions of mid-age women reporting each activity pattern (walking only 42.6%; mixed'
activities 38%; moderate only 3.2%; vigorous only 0.9%) were essentially unchanged, but the median
total activity time reported by women who only walked and by those who reported mixed activities
increased by a median of 60 minutes per week [walking only: M3 median 120 (60-240); M4 median
180 (90-300); mixed: M3 median 300 (180-480); M4 median 360 (230-570)]. This is consistent with
the overall increase in walking reported below.
Among the older women the most common pattern of physical activity was also only walking, with
almost 40% reporting only walking at O2 [median time 120 (60-240) mins per week], while 21.2%
reported mixed activities [median time 360 (25-595) mins]. Once again, women in this mixed group
reported notably higher levels of physical activity. Almost 10% reported doing only moderate [8.6%,
median time 240 (120-465) mins] or only vigorous [0.8%, median time 120 (60-180) mins] activities.
In this older cohort 29.5% reported no activity in response to the walking, moderate and vigorous
activity questions, and 60% of these women reported no house or yard work either. At O3, the
proportion of older women reporting no activity increased to 37.3%, but for those women who
continued to be active, activity times remained largely unchanged from O2.
How Active are Australian Women?
65
Physical Activity and Health in Mid-Age and Older Women
Physical activity and paid and unpaid work
Median values for physical activity (MET.mins/week) by occupation categories are shown in Figure 3.3.
These cross-sectional data were from the M4 survey in which women were asked to indicate their main
occupation in terms of the Australian Standard Classification of Occupations (Australian Bureau of
Statistics, 1986). There was a wide range of physical activity levels within each occupation group; the
lowest median physical activity level was reported by women who identified as intermediate production
or transport workers (category 7, which includes occupations such as machine operators and bus
drivers). However, although strikingly low, this estimate was based on data from only 63 women.
The next lowest levels of physical activity were reported by women in the labourer or related worker
category (category 9, includes cleaner, factory worker, kitchen hands, etc), followed by women in the
advanced clerical or service category (category 5, includes personal assistants, flight attendants) and
those in the intermediate clerical, sales or service category (category 6, includes data entry operators,
child care workers, hospitality workers etc) (see Figure 3.3).
Median values for physical activity (METmins/week) by hours of paid work are shown in Figure 3.4.
The most active women were those who reported 1-24 hours of paid work per week.
66
1 2 3 4 5 6 7 8 9 *
0
750
1500
2250
3000
3750
ME
T/m
ins
perw
eek
ASCO: Australian Standard Classification of Occupations. 1: Manager (eg magistrate, school principal, etc) N=720; 2: Professional (eg nurse, teacher, etc) N=1865; 3: Associate Professional (eg branch manager, police officer, etc) N=720; 4: Tradesperson (eg cook, hairdresser, etc) N=263; 5: Advanced Clerical or Service Worker (eg personal assistant, flight attendant, etc) N=593; 6: Intermediate Clerical, Sales, or Service Worker (eg clerk, child care worker, etc) N=1137; 7: Intermediate Production or Transport Worker (eg machine operator, bus driver, etc) N=63; 8: Elementary Clerical, Sales or Service Worker (eg mail clerk, sales assistant, etc) N=475; 9: Labourer or Related Worker (eg cleaner, factory worker, kitchen hand etc) N=584; 10: No Paid Work N=2821.
Figure 3.3 Box plots for physical activity by occupation category (M4 data; N=9241).
1 2 3 4 5 6 7 8 9 10
How Active are Australian Women?
67
Physical Activity and Health in Mid-Age and Older Women
none 1-24 hours 25-40 hours 41+ hours
Hours in paid work per week
0
750
1500
2250
3000
3750
ME
T/m
inpe
rwee
k
Figure 3.4 Box plots for physical activity by hours of paid work (M4 data; N=10,041).
68
3.4 Trends in Physical Activity Over Time
In this section, changes over time are based only on data from women who answered the physical
activity questions in two consecutive surveys: M3 and M4 for the mid-age cohort (N=9,167) and O2
and O3 (N=7,137) for the older cohort. As the physical activity questions asked in these surveys were
identical, the data allow for exploration of changes in physical activity over time in the same sub-
groups of women at each survey.
As these women were more likely to be categorised as active at baseline than those women who did
not answer the physical activity questions at all surveys, and those who did not continue responding to
the surveys, it is likely that estimated levels of physical activity based on these data are greater than
the true population levels.
Median values for total MET.mins of physical activity at M3 and M4 and at O2 and O3 are shown in
Figure 3.4. It can be seen that physical activity levels were higher in the mid-age women in 2001,
than in the older women in 1999 [M3 (2001): median 540 (Inter-quartile range, IQR, 135-1170]; O2
(1999): median 360 (IQR 0-1025)]. These data confirm previous cross-sectional findings of decreasing
physical activity with increasing age (Armstrong et al., 2000).
However, rather than declining with age, among the mid-age women, physical activity increased in
the three years between M3 and M4 [M4 median 720 (IQR 210-1440)]. In contrast, among the older
women, median total MET.mins decreased in the three years between O2 and O3 [O3 median 210
(IQR 0-900)]. These overall patterns of increasing physical activity in the mid-age cohort and
declining physical activity in the older cohort were largely consistent across geographic areas.
Physical activity levels are INCREASING in mid-age women
(1998-2004). This is largely attributable to walking.
Physical activity levels are DECREASING in older women (1999-
2005). This is attributable to increasing numbers of women who
report NO activity, rather than decreases in the amount of activity
reported by those who report any.
How Active are Australian Women?
69
Physical Activity and Health in Mid-Age and Older Women
Physical activity was measured in MET.mins/week. (600 MET.mins is equivalent to 150 minutes of moderate intensity (4 METs) physical activity per week, and is equivalent to meeting current guidelines for recommended levels of physical activity).
Figure 3.5 Median and inter-quartile ranges for physical activity in the mid-age cohort at M3 (2001) and M4 (2004) (N=9,167) and in the older cohort at O2 (1999) and O3 (2002) (N=7,134).
0
300
600
900
1200
1500
1800
M3 M4 O2 O3
MET
.min
s/w
eek
mid-age older
70
Trends in walking over time
Walking was reported by a large proportion of women in both cohorts, either as the sole form of physical
activity, or in combination with other activity types. As such, it is useful to consider walking patterns in
isolation from the more generalised physical activity score. Median times for walking at Surveys 2, 3 and
4 are shown in Figure 3.6. Data from M2 are included here for the mid-age women as they are
unaffected by the different wording of the moderate activity question in that survey. In the mid-age
cohort (N=8,693) there is a clear increase in time spent walking at each survey [M2 median 60 (0-150);
M3 median 90 (25-200); M4 median 120 (30-240) mins].
In contrast, in the older cohort (N=5,611), walking time decreased, so that by O4 the median walking time
was zero [O2 median 60 (0-180); O3 median 30 (0-150) mins, O4 median 0 (0-120)]. This was
attributable to a decrease in the number of older women reporting any walking, rather than a decrease in
time spent walking among those who continued to walk. When these walking data were considered by
location, it was clear that the increase in walking in the mid-age cohort and the decrease in walking in the
older cohort were seen consistently across areas of residence.
How Active are Australian Women?
71
Physical Activity and Health in Mid-Age and Older Women
Figure 3.6 Median and inter-quartile ranges for time spent walking in the mid-age women (at M2, M3 and M4; N=8,693) and the older women (at O2, O3 and O4; N=5,611).
0
30
60
90
120
150
180
210
240
270
M2 M3 M4 O2 O3 O4
min
utes
/wee
k
mid-age older
72
Changes in physical activity categories over time
Mosaic plots to show changes in physical activity categories for the mid-age (M3 to M4) and older (O2
to O3) women are shown in Figure 3.7. For simplification, the very low and low categories (see page
54) have been combined to form one low category and the moderate and high categories have been
combined to form a single active category.
Between M3 and M4, just over half (56%) the mid-age women remained in the same physical activity
category (mid-coloured bars in the mosaic plot in Figure 3.7), while almost one in five (17.6%) moved
into a lower physical activity category (lighter bars), and more than one in four (26.4%) moved into a
higher category (darker bars). These data are commensurate with the overall increase in physical
activity in the mid-age group reported above (see Figure 3.7).
However, only about one third of the women were categorised as active at both times (ie meeting
guidelines). This is in contrast with the point prevalence estimates of the proportions of women
categorised as active at M3 (44.8%) and M4 (54.2%). About 15% of the mid-age women remained in the
low category (ie they reported some activity, but insufficient to meet the guidelines) and only 7%
remained in the none category, at both surveys (see Table 3.1).
The mosaic plot showing changes in physical activity categories for the older women from O2 to O3 is
markedly different from that of the mid-age women (see Figure 3.7). Although a similar proportion (to
that seen in the mid-age cohort, 56%) remained in the same category at both O2 and O3 (57.3%,
mid-coloured bars in Figure 3.7), 26.1% of the older women moved into a lower category (lighter
bars), while 16.6% moved into a higher category (darker bars). Note that these proportions are
almost exactly opposite to those reported for the mid-age women, and are consistent with an overall
decline in physical activity in this cohort between these two surveys.
In contrast with the point prevalence estimates from O2 (33.8%) and O3 (33.0%), the proportion of
older women who were consistently active (ie meeting guidelines) at these two surveys was only
23.1%. The proportion in the low activity category at both surveys (13.0%) was similar to that seen
in the mid-age cohort (15.5%). More than one fifth (21.2%) of this older cohort remained in the none
category at O2 and O3 (see Table 3.2).
How Active are Australian Women?
73
Physical Activity and Health in Mid-Age and Older Women
Cross-sectional estimates based on data from all women at each
survey
Prospective data from the same women at each
survey
O2 N=9,123
%
O3 N=8,052
%
O2/O4 N=7,137
%
Active 33.8 33.0 23.1
Low active 35.0 27.3 13.0
Sedentary (none) 31.3 39.7 21.2
Increasers - - 16.7
Decreasers - - 26.0
Table 3.1 Estimates of physical activity from consecutive surveys of mid-age women.
Table 3.2 Estimates of physical activity from consecutive surveys of older women.
Cross-sectional estimates based on data from all women at each
survey
Prospective data from the same women at each survey
M3 N=10,671
%
M4 N=10,163
%
M3/M4 N=9,167
%
Active 44.8 54.2 33.5
Low active 37.1 29.4 15.5
Sedentary (none) 18.1 16.4 7.0
Increasers - - 26.4
Decreasers - - 17.6
74
In these mosaic plots the width of each bar on the x axis shows the proportion of women in each physical activity category at Survey 3 (mid-age) and at Survey 2 (older), and the height of each bar on the y axis shows the proportion in each physical activity category at the following survey, three years later. The area of each box is therefore proportional to the number of women in that change category. The darker boxes show the proportions of women whose physical activity category increased between surveys and the lighter boxes show the proportions of women whose physical activity category decreased between surveys. The mid-coloured boxes show the proportions of women whose physical activity category did not change between surveys.
Figure 3.7 Changes in physical activity in the mid-age (N=9,167) and older (N=7,137) cohorts.
(a) Mid-age
(b) Older
none low active
non
e
lo
w a
ctiv
e
M4
SU
RVEY
M3 SURVEY
4.6%
5.4%
7.0%
16.4%
15.5%
5.6%
33.5%
8.9%
3.1%
none low active no
ne
lo
w a
ctiv
e
O3
SU
RVEY
O2 SURVEY
3.2%
5.7%
21.2%
7.7%
13.0%
10.5%
23.1%
8.7%
6.9%
How Active are Australian Women?
75
Physical Activity and Health in Mid-Age and Older Women
3.5 Factors Associated with Physical Activity Changes over Time
Mid-age women
Analyses were conducted to see whether demographic characteristics (eg area of residence, education,
country of birth, marital status, income, hours in paid work), other health behaviours (eg smoking,
alcohol use), weight variables (eg body mass index and weight change) and indicators of illness
(number of chronic health problems), stress (number of life events experienced) and caring
responsibilities (for children under 16 years or for a person with a long tem illness, disability or frailty)
were associated with changes in physical activity category in the mid-age cohort.
A summary of the results of logistic regression analyses using data from women who were active at
both M3 and M4, and from women whose physical activity category increased or decreased between
these two surveys are shown in Table 3.3. Area of residence, country of birth and marital status were
not associated with changes in physical activity in any of the analyses.
The analyses found that women who were categorised as active at both surveys (ie those in the active
category at the top right of the mosaic plot in Figure 3.7, N=3,058) were more likely than those in the
none category at both these surveys (at the bottom left of the mosaic plot, N=642) to have at least
high school education, to have household income of at least $500 per week, to work up to 34 hours
per week in paid work, to have experienced at least three stressful life events, and to provide care for
someone with a long-term illness, disability or frailty. They were less likely to care for children under
16 years, to be current smokers, non-drinkers or high-risk drinkers, and to report two or more chronic
health problems. In relation to weight, women in this group were less likely to be underweight,
overweight or obese, and less likely to be in any of the weight gain categories, than the sedentary
women (see Table 3.3).
76
Table 3.3 Summary of demographic and health-related variables associated with three categories of physical activity change in the mid-age women (N=7,721)
Active-Active N=3,058
Increasers N=2,414
Decreasers N=1,607
Education (higher) +++ +++ ��
Income (higher) + ++ ns
Paid work (1-34 hours) ++ + ns
Smoking ��� ��� +++
Alcohol ��� �� +
Body mass index (obese) ��� �� +++
Weight gain � � +++
Stressful life events + + ns
Provide care (child under 16 years) � ns ns
Provide care (adult) + + ns
Number of chronic health problems ��� � ++
+++ or ��� p <0.001
++ or �� p <0.01
+ or � p <0.05
ns not significant
How Active are Australian Women?
77
Physical Activity and Health in Mid-Age and Older Women
Healthy, Wealthy and Wise?
Mid-age women who were categorised as ACTIVE at both M3 and M4,
or who became active between M3 and M4, tended to be healthy
weight, non-smokers, low-risk drinkers, to work part-time, to have at
least high school education, and to have high income and few chronic
health problems. They were also more likely than sedentary women
to provide care for someone with a long term health problem.
In contrast, those whose physical activity DECREASED at consecutive
surveys were more likely to be smokers, to not drink alcohol, to be
gaining weight and to be overweight or obese. They were less likely
to have tertiary education.
Women whose physical activity increased between M3 and M4 (ie those depicted by the darker
rectangles of the mosaic plot in Figure 3.7; N=2,414) had similar characteristics to those in the
consistently active category, in that they were more likely than the women who remained sedentary to
have at least high-school education, to be in a higher income bracket, to work up to 34 hours per
week in paid work, to have experienced at least four stressful life events, and to provide care for
someone with a long-term health problem. As was the case for the consistently active women, the
increasers were less likely than women who remained sedentary to be smokers or non-drinkers, to
have two or three chronic conditions, to be underweight, overweight or obese, or to be weight gainers
(see Table 3.3).
Women whose physical activity decreased between M3 and M4 (ie those included in the lighter bars of
the mosaic plot in Figure 3.7; N=1,607) were characterised by significant associations with six of the
variables shown in Table 3.3. Compared with women who were active at both surveys, the women
whose physical activity category decreased were less likely to have completed high school. They were
more likely to be current smokers and non-drinkers, to be obese, to be weight gainers (low or
moderate) and to report three chronic conditions (see Table 3.3).
78
Older women
Analyses were also conducted to see whether demographic characteristics (eg area of residence,
education, country of birth, marital status, ability to manage on income), other health behaviours (eg
smoking, alcohol use), weight variables (eg body mass index and weight change), and indicators of
illness (number of chronic health problems) and caring responsibilities (for a person with a long tem
illness, disability or frailty) were associated with changes in physical activity category in the older
cohort. In general, more of these variables were associated with the physical activity change
categories in the older women than in the mid-age group. The results of multivariate analyses are
summarised in Table 3.4.
The women who were categorised as active at O2 and O3 (ie top right hand box of the mosaic plot in
Figure 3.7, N=1651) were characterised by significant positive associations with four variables, and
significant negative associations with seven variables. Compared with women who remained
sedentary, they were more likely to have at least high school education, to have been born outside
Australia in an English-speaking country, to be widowed, and to report that managing on their income
was easy. They were less likely to live in an other rural or remote area, to be current or former
smokers, to be non-drinkers, and to have caring responsibilities. In terms of weight change, the
women who were active at both surveys were less likely than those who remained sedentary to be
weight losers, moderate or high weight gainers, or overweight or obese; they were also less likely to
report any chronic health problems (see Table 3.4).
Women whose physical activity increased from O2 to O3 (ie those in the dark boxes in the mosaic
plots in Figure 3.7, N=1,189) were similar to those who were consistently active in several respects.
They were more likely than the women who were consistently sedentary to have had a high school
education, to have been born outside Australia, and to be single (separated, divorced, never married
or widowed). They were also less likely to be current smokers, non-drinkers, to have caring
responsibilities and to report two or more chronic conditions. In relation to weight, they were less
likely to be in the weight loser or moderate weight gainers categories and less likely to have a body
mass index in the overweight or obese categories (see Table 3.4).
As was the case for the mid-age women, fewer factors were associated with the decreasing physical
activity category between O2 and O3. The women whose physical activity category decreased (ie
those included in the lighter bars in the mosaic plot in Figure 3.7, N=1,857), were more likely than the
women who were consistently active to be smokers and non-drinkers and to report two or more
chronic conditions. They were also more likely to be in the weight loser or high gainer category and to
have a body mass index in the obese range (see Table 3.4).
How Active are Australian Women?
79
Physical Activity and Health in Mid-Age and Older Women
Table 3.4 Summary of demographic and health-related variables associated with three categories of physical activity change in the older women (N=4,697).
Active-Active N=1,651
Increasers N=1,189
Decreasers N=1,857
Education (higher) +++ +++ ns
Area of residence
(rural/remote) - ns ns
Country of birth (other English)
++ + ns
Marital status
(widowed/single)
++ ++ ns
Manage on income + ns ns
Smoking ��� �� +
Alcohol ��� ��� +
Overweight/obese ��� ��� +++
Weight gain ��� ��� ++
Provide care (adult) (yes)
� �� ns
Number of chronic health problems
��� ��� +++
+++ or ��� p <0.001
++ or �� p <0.01
+ or � p <0.05
ns not significant
80
Who are the Active Older Women?
Overseas born women who are widowed, healthy (ie have few
chronic conditions, and are healthy weight, non-smokers, low risk
drinkers), and relatively wise (at least high school education) are
more likely to be ACTIVE or to become active when they are in their
late seventies.
In contrast, those who report new chronic health problems are
likely to drop-out of physical activity. These women are more likely
to also have weight problems, and to be smokers and non-drinkers.
How Active are Australian Women?
81
Physical Activity and Health in Mid-Age and Older Women
3.6 Associations between Life Events and Changes in Physical Activity
Mid-age women
Analyses were conducted to assess whether any of the life events reported by women were associated
with changes in physical activity between M3 and M4. The complete list of life events included in the
analyses for the mid-age women (and the proportion of women who reported each one) was
� birth of a grandchild (43.8%);
� going through menopause (20.8%);
� major decline in health of other close family member or friend (20.5%);
� major decline in health of spouse or partner (9.2%);
� major personal illness (10.6%); major personal injury or surgery (5%);
� major surgery (not including dental work) (10.9%);
� major personal achievement (11.9%);
� starting a new personal relationship (6%);
� infidelity of spouse /partner (4.8%);
� break up of close personal relationship (7.3%); divorce (5.2%);
� major conflict with children (8.3%); child/others leaving home (15%);
� death of spouse or partner (2.1%); death of a child (2.2%);
� death of close family member (21.3%) or friend (14.5%);
� changing hours/conditions type of work (15.4%);
� retirement (9.2%); spouse/partner retiring (9.6%);
� spouse/partner made redundant (7.3%); decreased income (18.1%);
� moving house (15.8%);
� natural disaster or house fire (4.7%); major loss/damage to property (3.4%):
� being robbed (7%); legal troubles or court case (7.1%);
� being pushed, grabbed, shoved etc (3.4%); forced into unwanted sex (2.6%);
� arrest or jail of family member or close friend (3.4%);
� self or family member involved with problem gambling (4.7%).
82
Only four of these life events were significantly associated with changes in physical activity. After
adjustment for area of residence, age, education, country of birth, income and weight change in each
model, the odds of increasing physical activity (ie being in any of categories depicted by the darker
bars in Figure 3.7), compared with maintaining physical activity at current levels (ie being in the mid-
coloured bars in Figure 3.7) were significantly higher for women who reported:
� a major personal achievement (OR=1.19; 95% CI -1.01,1.39);
� death of spouse (OR=1.61; 95% CI 1.13, 2.31); or
� retirement (OR=1.29; 95% CI 1.08, 1.53)
than for women who did not report these events.
The only life event that was significantly associated with decreasing physical activity was
� infidelity of spouse or partner (OR=0.57, 95% CI 0.40-0.80)
Women who reported this were less likely to decrease their physical activity category than those who
did not.
How Active are Australian Women?
83
Physical Activity and Health in Mid-Age and Older Women
Older women
Analysis of associations between life events and changes in physical activity were also conducted for
the older women. Life events included in these analyses (and the proportion of women who reported
each one) were
� major personal illness or injury (11.2%);
� major surgery (not including dental work) (11.4%);
� major decline in health of spouse or partner (9.3%);
� major decline in health of other close family member or friend (14.1%);
� death of spouse or partner (7.4%);
� death of a child (1.9%);
� death of other close family member or friend (15.1%);
� decreased income (5.1%);
� moving house (8.3%);
� being robbed (2.7%);
� moving into an institution (1.1%) and
� spouse or partner moving into an institution (1.1%).
Few of these life events were associated with changes in physical activity. Not surprisingly, after
adjustment for area of residence, age, education, country of birth, income source, and weight change
in each model, the odds of decreasing physical activity (ie being included in the lighter bars in the
mosaic plots in Figure 3.7) compared with maintaining current level of physical activity (ie being
included in the mid-coloured bars in the mosaic plots in Figure 3.7) were greater in women who
� reported a major personal illness or injury (OR=1.66; 95% CI: 1.41, 1.96) and in
� women who reported major surgery (OR=1.33; 1.13, 1.58)
than in women who did not report these events.
No life event was significantly associated with increases in physical activity; there was however a trend
for women who reported death of their spouse or partner to have higher odds for being in this
category [OR=1.24 (0.98, 1.56); p=0.076]. As there was also a tendency for death of spouse/partner
to be associated with less likelihood of decreasing physical activity (OR=0.83; 95% CI: 0.67-1.04;
p=0.11), we conclude that this life event is an important correlate of changing physical activity levels
in older women, and may reflect the increased discretionary time available to women after the death
of their partner, especially if they had had a significant caring role (Byles, Feldman, & Dobson, 2006).
84
How Active are Australian Women?
85
Physical Activity and Health in Mid-Age and Older Women
3.7 Discussion
Overall, these data suggest that, while notable proportions of women in both cohorts changed their
physical activity category over consecutive surveys, on a population basis, overall levels of physical
activity are increasing in mid-age women at this age (early fifties) and decreasing in older women (in
their late seventies). In both cohorts, demographic characteristics (eg education, income) and health
variables (eg smoking, drinking, chronic illness) were associated with the physical activity change
categories. Women who were consistently active over two surveys, or who became active, tended not
to be smokers, but reported drinking safe amounts of alcohol. They also worked part-time and had
fewer chronic health problems than consistently sedentary women. This is important, because in the
older cohort major illness and surgery were the main factors associated with decreasing physical
activity. These results underscore the importance of preventing chronic illness in the middle-years by
maintaining a healthy lifestyle which includes physical activity.
Interestingly, providing care or assistance to someone with a long-term illness, disability or frailty was
associated with being or becoming active in the mid-age cohort, but the active older women were less
likely to be a carer for someone with these problems. It is unclear why the active mid-age women
were more likely to report these caring duties, but previous analyses of data from the mid-age ALSWH
cohort have shown complex relationships between caring and hours in paid work, and it is possible
that women who reduce their hours of paid work in order to cope with caring duties may then have
more time for physical activity. Analyses of the complex time course relationships
between changes in caring, hours of paid work and physical activity are ongoing. In light of the
increasing numbers of older people in the population, keeping mid-age women sufficiently fit and
healthy (through physical activity) for potential increased caring roles may be another reason why
governments should invest more in promoting physical activity to this population group.
Finally, marital status was not associated with physical activity in the mid-age women, but in the older
cohort, not being married and being single were associated with remaining or becoming active. In the
life events analyses, death of spouse or partner was associated with increasing activity in both the
mid-age and older women. Previous analyses of the ALSWH data have shown that, in younger adult
women, getting married is associated with decreasing levels of physical activity (Brown & Trost, 2003).
86
For young women, getting
married is associated with
decreasing physical activity.
Brown & Trost, 2003
For mid-age and older
women, loss of spouse is
associated with increasing
physical activity
ALSWH
How Active are Australian Women?
87
Physical Activity and Health in Mid-Age and Older Women
This finding, and the finding that marriage was the most significant predictor of time spent in paid and
unpaid work in 1991 (Bittman, 1991), suggest that at least some of the time pressures faced by
women who try to fit physical activity into their day are caused by their increased contribution to
unpaid tasks in the household, which are attributable to having a spouse. However, more recent data
from the HILDA survey (Headey, Warren, & Harding, 2006) suggest that, while women still do the
majority of housework, the total hours that men and women spend in paid and unpaid (household)
work is very similar (about 60 hours a week) when couples are in full-time employment. However,
women in part-time paid work (20 hours per week on average) report spending more than twice as
much time in household tasks (19.1 hours per week) as men who work comparable part-time hours
(7.4 hours per week in household work). In the ASLWH survey women who report 1-34 hours of paid
work appear to find more time for physical activity, perhaps reflecting the more flexible nature of their
paid and unpaid working roles.
88
KEY ISSUES
On a population basis, overall levels of physical activity are increasing in
mid-age women and decreasing in older women.
In older women, major illness and surgery are the main factors
associated with decreasing physical activity.
In mid-aged women, providing care to someone with a long-term illness,
disability or frailty is associated with being or becoming active.
In older women, being single is associated with remaining or becoming
active.
In both mid-age and older women, loss of spouse or partner is associated
with increasing activity.
Relationships Between Physical Activity and Selected Health Outcomes
89
Physical Activity and Health in Mid-Age and Older Women
4. RELATIONSHIPS BETWEEN PHYSICAL ACTIVITY AND SELECTED HEALTH OUTCOMES IN MID-AGE AND OLDER WOMEN
4.1 Introduction
Part one of this report provided an update of the epidemiological evidence relating to physical activity
and the primary prevention of six health problems which have been identified as national health
priorities for Australia ie cardiovascular disease, diabetes, cancer, mental health, musculoskeletal
health (osteoarthritis) and injury (falls). The limited evidence on relationships between physical
activity and reproductive health was also reviewed.
In a report for the Australian Government Department of Health and Ageing in March 2006, we
confirmed some of the associations between physical activity and these health outcomes in the mid-
age and older cohorts of the Australian Longitudinal Study on Women's Health. For example, among
the mid-age and older women, the prevalence of hypertension and both prevalence and incidence of
heart disease were statistically significantly higher among mid-age and older women who reported low
levels of physical activity, compared with those who reported at least the moderate level of physical
activity which is commensurate with meeting the physical activity guidelines (ie 30 minutes on most
days each week). Similarly, the prevalence of diabetes, osteoporosis, and arthritis were significantly
higher among women who reported little or no physical activity, compared with those achieving at
least moderate levels. This was particularly true for the older cohort, presumably because the
numbers of mid-age women reporting these health problems is, as yet, too small to demonstrate
significant associations with physical activity.
90
In contrast, the numbers of women reporting symptoms and conditions that are indicative of the
development of some of the health problems reviewed in Part One has been relatively high, ever since
the first survey in 1996. Therefore, for the final part of this report, prospective associations between
physical activity and the reporting of selected symptoms and conditions are examined and discussed.
The symptoms were selected on the basis of their potential to build on the information presented in
Part One of this report, and to contribute to our understanding of the wider health benefits of physical
activity. The selected symptoms/conditions and their related national health priority areas are
� menopausal symptoms in mid-age women (women's reproductive health)1
� stiff or painful joints and arthritis in mid-age and older women (musculoskeletal health)
� anxiety and depression in older women (mental health)
� memory problems in older women (ageing, cognitive decline)
� falls and fractures in older women (injury).
The report concludes with data on the relationships between physical activity and general physical and
mental well-being, as measured by the SF36 (which provides indicators of eight dimensions of health
and well-being, including: physical functioning; the role of physical functioning in performance of work
and daily activities; bodily pain; general health; vitality; social functioning; the role of emotional
problems on work and other daily activities; and mental health) and on the relationships between
physical activity and health service use and costs, in both the mid-age and older women.
1 Although this is not a national health priority area, it is a significant women's health issue.
Relationships Between Physical Activity and Selected Health Outcomes
91
Physical Activity and Health in Mid-Age and Older Women
4.2 Does Physical Activity Protect Against Menopausal Symptoms in Mid-Age Women?
For mid-age women, going through menopause is an important transition, which can be accompanied
by many health problems and decreased quality of life (McVeigh, 2005; Utian, 2005). At this time,
women typically complain about three types of symptoms; vasomotor symptoms (hot flushes and night
sweats), somatic symptoms (such as joint pain and headaches), and psychological symptoms (such as
mood and sleep disturbances) (Greene, 1998). These symptoms may begin 5 to 10 years before
cessation of the menstrual cycle, and may last 10-20 years after menopause (Berg, Gottwall, Hammar,
& Lindgren, 1988).
There is conflicting evidence about the role of physical activity in ameliorating menopausal symptoms,
with some intervention studies showing some positive results (Kemmler, Lauber, Weineck, Hensen,
Kalender, & Engelke, 2004; Slaven & Lee, 1997) and others showing no effects of physical activity
(Aielle, Yutaka, Tworoger, Ulrich, Irwin, Bowen, et al., 2004). The relationship between physical
activity and menopausal symptoms is therefore equivocal, and may be different for vasomotor
symptoms, somatic symptoms or psychological symptoms (Greene, 1998). The Australian Longitudinal
Study on Women’s Health presents an opportunity to track changes in these menopausal symptoms in
women who are at different stages of the menopause transition, and to see whether physical activity
ameliorates any of the common vasomotor, somatic or psychological symptoms in menopause.
The aim of this analysis was to assess the relationship between changes in physical activity (M3 to M4)
and self-reported vasomotor, somatic and psychological symptoms at M4. Data were excluded from
the analyses if the women reported difficulty walking 100 meters, if they had a menopausal score of
14 or above at S2, if menopause had been induced (due to hysterectomy or oopherectomy) or was
unable to be classified at any survey, if they were taking antidepressants or oral contraceptives, if they
were taking hormone replacement therapy at S2, and if they did not answer the physical activity
questions at S2, S3, or S4.
Responses to questions about the frequency of hot flushes, night sweats, depression, severe tiredness,
stiff or painful joints, headaches/migraines, and feeling nervous were used to create a menopausal
symptoms score (ranging from 0 to 21), with sub-scores for vasomotor symptoms (hot flushes and
night sweats; range 0 to 6), somatic symptoms (stiff or painful joints and headaches/migraines; range
0 to 6), and psychological symptoms (depression, severe tiredness and nervousness; range 0 to 9).
92
Menopausal status was defined for M3 and M4 on the basis of self-report of menstrual bleeding: no
menstrual bleeding in the last 12 months (post-menopause); menstrual bleeding in the last 12 months,
but not in the last 3 months or with different menstrual frequency compared with the previous year
(peri-menopause); and menstrual bleeding in the last 3 months and in the last 12 months and with the
same frequency as in the previous year (pre-menopause) (Dudley, Hopper, Taffe, Guthrie, Burger, &
Dennerstein, 1998). Five menopause transition categories were defined: pre-menopause at both times
(pre–pre); transition from pre-menopause to peri-menopause (pre–peri); peri-menopause at both
times (peri–peri); transition from pre- or peri-menopause to post-menopause (pre/peri–post); and
postmenopause at both times (post–post).
Menopausal symptoms at M4, by each menopause transition category (M3 to M4) and by physical
activity category at M3 are shown for 3,330 women in Figure 4.1. Women who were undergoing the
menopause transition (e.g. pre-peri, peri-peri, pre/peri-post) and women who were postmenopausal
had higher scores than women who remained pre-menopausal. This was particularly true for the
vasomotor symptoms. Total menopausal symptoms score was slightly higher in sedentary women,
which was mainly due to a higher reporting of psychological symptoms in this group compared with
the more active women (see Figure 4.1).
The relationship between changes in physical activity (M3 to M4) and menopausal symptoms at M4
was examined using regression analyses, with adjustment for history of depression, highest
educational qualification, area of residence, smoking status, body mass index, change in weight
between surveys, and menopause transition category. Increases in physical activity were associated
with a very small reduction in somatic symptoms [B=-0.003 (-0.005, -0.001)]. In other words, an
increase in moderate physical activity of one hour per week was (240 MET.minutes) was associated
with a reduction of less than one unit on the menopause score. It is unlikely that this finding would
have any clinical significance.
Relationships Between Physical Activity and Selected Health Outcomes
93
Physical Activity and Health in Mid-Age and Older Women
(a) Total menopause symptoms score
(b) Scores for the three symptoms scales by menopause transition
(c) Scores for the three symptom scales by physical activity category
Figure 4.1 Mean menopausal symptoms scores by menopause transition (M3 to M4) and physical activity categories at M3 (N=3,330).
00.5
11.5
22.5
3
vasomotor somatic psychological
pre-pre pre-peri peri-peri pre/peri-post post-post
0
0.5
1
1.5
2
2.5
3
vasomotor somatic psychological
sedentary low moderate high very high
012345678
pre-p
re
pre-p
eri
peri-
peri
pre/
peri-
post
post-
post
sede
ntary low
moder
ate high
very
high
94
Changes in weight were more strongly associated with vasomotor and somatic symptoms, but not with
psychological symptoms. Women who gained more than 5kg between surveys reported more
vasomotor symptoms than women whose weight remained stable [(B=0.29 (95% CI=0.12, 0.47)].
Women who lost more than 5kg reported fewer vasomotor [(B=-0.34 (-0.55, -0.13)] and somatic
[(B=-0.19 (-0.36, -0.02)] symptoms than women whose weight remained stable. Women with a
history of depression were also more likely to report more somatic [(B=0.26 (0.11, 0.40)] and
psychological symptoms [(B=0.56 (0.39, 0.74)] than women without a history of depression. A
history of depression was not related to vasomotor symptoms.
In summary, changes in physical activity were not independently related to vasomotor symptoms or
psychological symptoms. Somatic symptoms were marginally reduced by increases in physical activity,
particularly in women who did not lose or gain more than 5kg. For women who lost or gained weight,
the change in weight was strongly associated with a decreased frequency of vasomotor and somatic
symptoms, respectively. For women who gained weight, this change was related to a higher
frequency of vasomotor symptoms. The exact role of weight change on menopausal symptoms now
merits further investigation, preferably in combination with objective physical activity measures.
Relationships Between Physical Activity and Selected Health Outcomes
95
Physical Activity and Health in Mid-Age and Older Women
4.3 Does Physical Activity Protect Against Stiff or Painful Joints and Arthritis in Mid-Age And Older Women?
Arthritis is a leading cause of pain and disability in Australia (Australian Institute of Health and Welfare,
2006), affecting 17% of the population (Access Economics, 2005). As is also the case in the United
States, more Australian women than men have arthritis (Access Economics, 2005; Centers for Disease
Control and Prevention, 1997), and the incidence and prevalence of arthritis increase with age
(Centers for Disease Control and Prevention, 1997; Seavey, Kurata, & Cohen, 2003). Mid-age and
older women are therefore, at particular risk.
In prospective population-based studies (Cheng, Macera, Davis, Ainsworth, Troped, & Blair, 2000;
Felson, Zhang, Hannan, Naimark, Weissman, Aliabadi, & Levy, 1997; Hart, Doyle, & Spector, 1999;
Seavey et al., 2004), physical activity has been identified as a potentially modifiable risk factor for
arthritis, with results of several studies suggesting that moderate to vigorous leisure-time physical
activity may be protective against the development of arthritis. However, the results are inconsistent,
and there is some evidence that specific forms of vigorous physical activity (such as football) may
contribute to the onset of arthritis, especially in men.
An association between physical activity and arthritis is physiologically plausible because moderate to
vigorous physical activities reduce the risk of injury to joints by strengthening the muscles around
them and by improving balance and joint mobility (Arthritis Foundation, 2005).
Participants in the mid-age and older cohorts of the ALSWH have been asked several times whether
they have experienced stiff or painful joints (never, rarely, sometimes, or often) in the previous 12
months and to report whether they have been diagnosed with or treated for arthritis in the previous 3
years. There is therefore an opportunity to examine the prospective relationships between physical
activity and both stiff or painful joints and the self-report of diagnosis with arthritis in both these
cohorts.
These analyses used data from mid-age and older women who answered the M3 and M4 and O2 and
O3 surveys, respectively. Data on physical activity and potential risk factors were from M3 and O2,
and data on the two outcomes (stiff or painful joints often in the previous 12 months and self-reported
diagnosis or treatment of arthritis in the previous 3 years) were from the following M4 and O3 surveys.
After adjusting for the over-sampling of women in rural and remote areas, 23.9% of the mid-age
women and 28.2% of the older women reported having stiff or painful joints often at M4 and O3
respectively. The prevalence of diagnosis or treatment for arthritis was 25.5% in the mid-age women
at M4 and 43.1% in the older women at O3.
96
Separate multivariate logistic regression models were computed for the two cohorts and the two
outcomes. In the analysis of stiff or painful joints2 data from 4780 mid-age and 3970 older women
were used, and the analyses were adjusted for education, area of residence, country of birth,
depression, number of chronic conditions, smoking status, and body mass index. Data from
participants who reported stiff or painful joints sometimes or often at the first survey (M3: 47.8% of
the mid-age women; O2: 45.1% of the older women), or who had missing physical activity data at
that survey, were excluded.
In the analysis of arthritis, data from 7,217 mid-age and 4,165 older women were used, and the
analyses were adjusted for income management, area of residence, depression, number of stressful
life events, number of chronic conditions, smoking status, alcohol status, and body mass index. Data
from participants who reported treatment or diagnosis of arthritis at the first survey (M3: 22.0% of the
mid-age women; O2: 41.8% of the older women), or who had missing physical activity data at that
survey, were excluded.
The results are shown in Figure 4.2. In the mid-age women, physical activity was not protective
against arthritis symptoms or arthritis. However, in the older cohort, low, moderate and high physical
activity protected against the onset of stiff or painful joints (low OR=0.72, 95% CI=0.55, 0.97;
moderate OR=0.54, 95% CI=0.39, 0.76; high OR=0.61, 95% CI=0.46, 0.82). High physical activity
was also protective against the onset of arthritis in this three year period (OR=0.74, 95% CI=0.59,
0.92) (See Figure 4.2).
These results indicate that physical activity is not protective against the onset of arthritis symptoms or
arthritis in mid-age women, at least over this 3-year period when they were 50-55 and 53-58 years
old. However, among the older women, low, moderate and high levels of physical activity (equivalent
to 75+ minutes of moderate-intensity physical activity each week) were found to be protective against
the onset of symptoms that precede and accompany arthritis in older women. Higher levels of physical
activity (the equivalent of 300+ min of moderate-intensity physical activity each week) were protective
against the onset of arthritis, in the three year period between O2 and O3, when the women were
aged between 73-78 and 76-81 years.
These results suggest that even low levels of physical activity are independently protective against
arthritis symptoms but high levels are required to protect against arthritis in older women. This
protection is not seen in mid-age women.
2 The analyses of the stiff and painful joints data are now published. For more details see Heesch, Miller, Brown (2007)
Relationships Between Physical Activity and Selected Health Outcomes
97
Physical Activity and Health in Mid-Age and Older Women
ORs for stiff or painful joints adjusted for education, area of residence, country of birth, depression, number of chronic conditions, smoking status, and body mass index. ORs for arthritis adjusted for income management, area of residence, depression, number of stressful life events, number of chronic conditions, smoking, alcohol, BMI.
Figure (a) adapted from Heesch et al, 2007
Figure 4.2 Odds ratios (and 95% CI) for associations between physical activity at M3/O2 and often having (a) stiff or painful joints (mid-age N=4,780; older N=3,970) and (b) arthritis (mid-age, N=7,217; older, N=4,165) at M4 and O3 respectively.
(b) Arthritis
(a) Stiff or painful joints
0
0.5
1
1.5
none
very
low low
moder
ate high
none
very
low low
moder
ate high
older womenmid-age women
0
0.5
1
1.5
none
very
low low
moder
ate
high
none
very
low low
moder
ate
high
older womenmid-age women
98
4.4 Does Physical Activity Protect Against Anxiety And Depression In Older Women?
As indicated in Part One of this report, both cross-sectional and prospective studies suggest that
physical inactivity may be positively associated with symptoms of depression (Brown, Ford, Burton,
Marshall, & Dobson, 2005; Dunn, Trivedi, & O’Neal, 2001; Fox, 1999; Paulska & Schwenk, 2000).
Much of the research in this area is however limited by small clinical samples with relatively short
follow-up, and the results of the prospective studies are somewhat mixed. Very few studies have
examined relationships between physical activity and anxiety. The inclusion of the Goldberg Anxiety
and Depression scale in the ALSWH provides an opportunity to examine prospectively the dose-
response relationship between physical activity and symptoms of depression and anxiety in older
women.
For these analyses, the data were from the 4,228 older women who completed surveys O1, O2 and
O3. Data from women who reported diagnosis or treatment for depression within the 3 years prior to
the 1999 (O2) survey, those unable to walk 100 meters in 1999 and those with missing values on any
factor were excluded. O2 data on physical activity, and on most other potential risk factors for anxiety
and depression (eg BMI, alcohol use, smoking status, marital status, having a chronic health condition,
and number of adverse life events) were included in the analyses. Education, measured at O1, was
also included.
The outcome measure was depression and anxiety as measured by the Goldberg Anxiety and
Depression Scale (GADS) at O3. The scale items have yes/no responses, and the total score is the
sum of 18 items, with higher values indicating more symptoms. Physical activity was categorized as
shown earlier in this report [eg none (< 40 MET.mins/week); very low (40-<300); low (300-<600);
moderate (600-<1200); and high (1200+)].
The analyses showed that women who were in any physical activity category above none at O2 had
significantly lower GADS scores at O3 than those in the none category. Women who completed high
school or had post-school education had lower scores on the GADS (p<.05), and being married, obese,
or a former smoker, having a chronic condition, or reporting at least one adverse life event were
associated with higher GADS scores (p<.05). Mean GADS score for each of the physical activity
categories, adjusted for these confounding variables and alcohol intake, are shown in Figure 4.3.
Relationships Between Physical Activity and Selected Health Outcomes
99
Physical Activity and Health in Mid-Age and Older Women
This figure shows that after adjusting for other health-related behaviours and demographic
characteristics, any level of physical activity greater than none was protective against the onset of
anxiety and depression in this three year period. This result suggests that older women in their 70s
can decrease their risk of developing depression and anxiety over a three year period by participating
in very low levels of physical activity. The greatest reduction in risk was observed among women who
reported high levels of physical activity, equivalent to 300+ minutes of moderate physical activity each
week.
100
Scores are adjusted for education, marital status, number of adverse life events, chronic conditions, alcohol, smoking and BMI.
Figure 4.3 Mean (SE) GADS scores at O3 for women in each physical activity category at O2 (N=4,228).
3
4
5
6
none very low low moderate high
Mea
n G
ADS
scor
e
Relationships Between Physical Activity and Selected Health Outcomes
101
Physical Activity and Health in Mid-Age and Older Women
4.5 Does Physical Activity Protect Against Memory Problems in Older Women?
While hair loss, hearing loss, and poor eyesight are considered normal components of ageing,
cognitive decline is more often associated with clinical conditions such as dementia and Alzheimer’s
Disease. Some degree of cognitive decline is, however, a normal, non-clinical, part of ageing. Despite
this, even non-clinical cognitive decline may impact on the capabilities required for independent living.
Loss of independence is distressing for older adults, and represents an increased emotional and
financial burden on families and society at large. An understanding of how to maintain or improve
cognitive functioning in late adulthood is therefore important for enhancing the well-being of older
adults.
There is emerging evidence from cohort studies to suggest that physical activity may be protective
against the onset of dementia. In a study of approximately 2000 men and women aged over 65 years,
with no existing diagnosis of dementia, Larson et al (2006) have shown that the risk of developing
dementia is 0.6 (95% CI 0.41 – 0.92, p<.05) in those who report exercising three times per week,
compared with those who are less active, over an average follow-up period of 6 years. Similarly, when
objective measures of physical function were used, better performance on a timed walking test was
associated with a lower risk of dementia (HR=0.79, 95% CI 0.70 - 0.89, p<.001) over the 6 years
(Wang, Larson, Bowen, & van Belle, 2006).
Although the ALSWH does not include measures of cognitive decline, it is notable that more than one
third of the mid-age women have reported having poor memory sometimes or often at the last two
surveys (M3: 34.9%; M4: 36.5%). In the older cohort the proportion of women reporting poor
memory increased from 33.9% of those who answered this question at O3 to 50.6% at O4. This is
consistent with estimates from the general population which show that up to 60% of older adults
complain of memory problems, and there is some evidence to suggest that these may be associated
with psychological and other health problems, with objective measures of cognitive functioning and, in
some cases, to be predictive of future dementia (Jonker, Geerlings, & Schmand, 2000; St John &
Montgomery, 2003; Comijs, Deeg, Dik, Twisk, & Jonker, 2002; Johansson, Allen-Burge, & Zarit, 1997;
Jorm, Butterworth, Anstey, Christensen, Easteal, Maller et al., 2004; Jungwirth, Fischerm Weissgram,
Kirchmeyr, Bauer & Tragl, 2004; Levy-Cushman & Abeles, 1998; Riedel-Heller, Matschinger, Schork, &
Angermeyer, 1999).
102
At O3 and O4, memory complaints in the older women were assessed in more detail using the Memory
Complaint Questionnaire (MAC-Q; Crook, Feher, & Larrabee, 1992). The MAC-Q is a six-item scale of
self-reported memory decline in which participants compare current memory ability with past
performance for given situations (eg remembering the name of a person just introduced to you).
Scores on this scale range from 7 to 35, and higher scores are considered to reflect perceived
cognitive decline.
Although no previous studies have explored relationships between physical activity and memory
complaints, in light of the emerging evidence on the relationships between physical activity and
dementia, we examined these relationships using data from O3.
For the following analyses women who reported diagnosed psychological or neurological conditions, or
the use of psychological or neurological medications were excluded, because these conditions and
medications are known to be detrimental to memory and cognitive functioning. Data from women
with complete responses to the physical activity items at O2 and O3 and to the memory items at O3
were included.
Among older women who had no psychological or neurological conditions, there was a cross-sectional
association between physical activity and scores on the MAC-Q at O3 (F(4, 4284)=2.94; p<.05). Although
significant, the differences between categories of physical activity were only slight (see Table 4.1).
Subsequent analyses showed that both physical activity levels and scores on the MAC-Q were
associated with optimism, mental health, health-related hardiness, and indicators of heart disease.
Higher scores on measures of optimism, mental health, and hardiness were associated with higher
levels of physical activity and reduced reporting of memory complaints. Use of heart medications was
associated with low levels of physical activity and high levels of perceived memory problems.
Variables that were associated at the univariate level with both physical activity and scores on the
MAC-Q were included in a logistic regression model. The model indicated a significant relationship
between physical activity and MAC-Q scores, with women in the highest physical activity category
about 25% less likely to have high MAC-Q scores (which was defined as MAC-Q >29). However, when
heart medications, health-related hardiness, and mental health were added to the model, the
relationship between high physical activity and memory complaints was no longer significant (see
Table 4.2).
Relationships Between Physical Activity and Selected Health Outcomes
103
Physical Activity and Health in Mid-Age and Older Women
Table 4.1 Mean (SE) MAC-Q scores for women in each physical activity category (O3 survey; N=4,289).
Physical Activity Category MET.mins/week N Mean MACQ score
(Standard Error)
Sedentary <40 1446 25.42 (.11)
Low 40 – 299 647 25.58 (.16)
Sufficient 300 – 599 568 25.58 (.17)
High 600 – 1199 708 25.36 (.15)
Very High >1200 920 24.98 (.13)
Table 4.2 Association between physical activity categories and MAC-Q score >29 in older women at O3 (N=4,298).
Unadjusted Adjusteda
OR 95% CI OR 95% CI
Physical Activity
< 40 MET mins 1 1
> 40 and <300 0.99 0.78 – 1.24 1.03 0.81 – 1.32
> 300 and <600 1.09 0.86 – 1.38 1.26 0.98 – 1.61
> 600 and <1200 0.92 0.73 – 1.15 1.10 0.87 – 1.39
> 1200 0.76 0.61 - 0.94 0.93 0.74 – 1.16
Heart Medications 0.86 0.70 – 1.06
Hardiness 0.96 0.94 – 0.97
Mental Health 0.98 0.97 - 0.98
Bold indicates significant association. a Odds ratios in the second model were adjusted for all variables in the model.
104
Although these cross-sectional analyses support an association between physical activity and memory
complaints as measured by the MAC-Q, the data suggest that memory complaints were significantly
less likely only among the most active women (ie those reporting an hour a day or more of moderate
intensity physical activity). The relationship does however appear to be mediated by health-related
hardiness and overall mental health, both of which are higher in the most physically active women.
This is consistent with previous findings of an association between health and memory complaints.
It is important to note, however, that the differences in MACQ scores between the active and
sedentary women were very small and that this may limit the extent to which we can consider these
differences to be meaningful in the lives of older women.
Relationships Between Physical Activity and Selected Health Outcomes
105
Physical Activity and Health in Mid-Age and Older Women
4.6 Does Physical Activity Protect Against Falls and Fractures in Older Women?
Falls are the leading cause of injury-related death and hospitalisation for people aged over 65 years
(Bell, Talbot-Stern, & Hennessy, 2000; Lilley et al., 1995; Lord, Sherrington, & Menz, 2001) and can
lead to placement in residential care (Donald & Bulpitt, 1999; Sattin et al., 1990; Tinetti & Williams,
1997). They may also have psychosocial consequences, such as decreases in self-esteem, daily
activity and social interaction, that result in isolation and loneliness (Lilley et al., 1995). Previous
studies suggest that up to 49% of community-dwelling women aged 65 years and over will experience
at least one fall over a 12-month period (Hill et al., 1999) and many of these will result in injury,
including fracture (Tinetti, 2003).
The role of physical activity in reducing falls remains controversial (Karlsson, 2004). Although there is
strong evidence to suggest that physical activity can reduce falls risk, through improvement of
strength and balance and through other physiological and psychological benefits (Latham, Anderson,
Bennett, & Stretton, 2003; Gillespie et al., 2006; Sherrington, Lord, & Finch, 2004), there is some
concern that physical activity may increase the risk of falls in vulnerable older people (Faber, Bosscher,
Chin, & van Wieringen, 2006). For example, it has been reported that older people who engage in
vigorous activity have a lower falls rate but have a higher risk of injuring themselves if they do fall
(Speechley & Tinetti, 1991).
The Australian Longitudinal Study on Women's Health (ALSWH) provides an opportunity to examine
prospective relationships between physical activity and increased risk of falls and broken or fractured
bones over a period of six years between O1 and O3. As it is one of few cohort studies which include
community-dwelling older women, it is now in a position to shed more light on the relationships
between physical activity and falls and fractures in a non-clinical sample.
For these analyses the main outcome measures were self-report of a fall to the ground in last 12
months and self report of broken bone or fracture at O3, which were reported by 18% and 5% of the
older women respectively. The main predictor variable was physical activity score at O1. Data from
respondents who reported a serious fall with injury at O1 and those were unable to walk 100m
unaided were excluded.
106
The results of these analyses are summarised in Figure 4.4. In the univariate model (Model 1),
women in the high and very high physical activity categories had decreased odds of reporting a fall to
the ground compared with those in the none/very low category (p<0.05). After adjustment for all
statistically significant confounding variables, risk of falling was 36% lower in the women in the very
high physical activity category (see Figure 4.4).
The analysis of relationships between physical activity at O1 and reporting a broken or fractured bone
at O3 found that respondents in the high/very high physical activity category at baseline were less
likely to report a broken bone in the six year follow-up period, than those in the none/very low
category (p< 0.05). The strength and statistical significance of this association remained unchanged
when the significant confounding variables were included in the model. In the adjusted model, risk of
falling was 47% lower in the women in the high/very high physical activity category (p<0.05) (see
Figure 4.5).
Our results support the findings from a number of prospective and case-control studies which have
shown statistically significant reductions in hip fracture among mid-age and older women who were
physically active compared with those who were sedentary (Feskanich et al., 2002; Gregg, Cauley,
Seeley, Ensrud, & Bauer, 1998; Hundrup et al., 2005; Karlsson, 2002).
In summary, these findings indicate that high levels of physical activity are associated with reduced
odds of falls and broken or fractured bones in older women who have not had a recent serious injury
from a fall.
Relationships Between Physical Activity and Selected Health Outcomes
107
Physical Activity and Health in Mid-Age and Older Women
0
0.5
1
1.5
none
/very
low low
modera
tehig
h
very
high
none
/very
low low
modera
tehig
h
very
high
adjusted odds ratios and 95% CIsunadjusted odds ratios and 95% CIs
ORs adjusted for area of residence, education, medication for nerves, leaking urine, number of chronic conditions, eyesight problems, elder vulnerability score and reporting a fall, injury from a fall or broken/fractured bone at O2.
Figure 4.4 Unadjusted and adjusted odds ratios for reporting a fall to the ground at O3, by O1 physical activity categories (N=6,468).
108
0
0.5
1
1.5
none
/very
low low
modera
te high
very
high
none
/very
low low
modera
te high
very
high
adjusted odds ratios and 95% CIsunadjusted odds ratios and 95% CIs
ORs adjusted for area of residence, country of birth, number of chronic conditions, eyesight problems, BMI, and reporting a previous fall, injury from a fall, or a broken/fractured bone at O2.
Figure 4.5 Unadjusted and adjusted odds ratios (and 95% confidence intervals) for reporting a broken or fractured bone at O3, by O1 physical activity categories (N=6,468).
Relationships Between Physical Activity and Selected Health Outcomes
109
Physical Activity and Health in Mid-Age and Older Women
4.7 Is There a Relationship Between Physical Activity and General Physical and Mental Well-Being in Mid-Age And Older Women?
Every survey of the ALSWH has included the Medical Outcomes Survey Short Form questionnaire
(SF36) to determine women's overall levels of physical and mental health. Most of the questions focus
on aspects of health and well-being in the four weeks prior to the survey. The SF36 has been widely
adopted as a reliable and valid measure of health-related quality of life (Ware, Keller, et al., 1995). It
provides indicators across eight dimensions of health and well-being including: physical functioning;
the role of physical functioning in performance of work and daily activities; bodily pain; general health;
vitality; social functioning; the role of emotional problems on work and other daily activities; and
mental health. Two summary measures: the Physical Component Summary Score (PCS) and the
Mental Component Summary Score (MCS) (which have demonstrated good discriminant validity in
differentiating populations that vary in physical and mental health status: Ware, Kosinski, et al., 1995),
are used in this section of the report.
In 2000 we reported on the cross-sectional relationship between physical activity scores and the PCS
and MCS scores in all three cohorts. The data for the mid-age (N=9,729) and older women (N=7,984)
are shown in Figure 4.6. Higher scores indicate better health. The means were adjusted for smoking
status, alcohol consumption, body mass index, occupational status, menopausal status (for mid-age
only), country of birth and area of residence (see Figure 4.6).
To overcome the limitations of these cross-sectional data, the new analyses reported here show the
relationships between (a) changes in physical activity between M3 and M4 and mean PCS and MCS
scores at M4 for the mid-age women, and between (b) changes in physical activity between O2 and
O3 and mean PCS and MCS scores at O3 for the older women. The physical activity change categories
were described in section 3.4 and relate to the mosaic plots in Figure 3.7.
110
Adapted from Brown, Mishra, Lee & Bauman, 2000
Figure 4.6 Cross-sectional relationships between physical activity categories and SF36 PCS scores (left hand side) and MCS scores (right hand side) for (a) mid-age women at M1 (N=9,729) and (b) older women at O1 (N=7,984) in 1996 (mean and 95% CI).
45
50
55
none low
moder
ate high
none
low
moder
ate high
(a) Mid-age women
45
50
55
none low
modera
tehig
hno
ne
low
modera
tehig
h
(b) Older women
Relationships Between Physical Activity and Selected Health Outcomes
111
Physical Activity and Health in Mid-Age and Older Women
Mean PCS and MCS scores by physical activity change category in the mid-age (N=8,437) and older
women (N=5,416) women are shown in Figure 4.7. All means are adjusted for BMI, smoking, alcohol,
education, country of birth (at baseline or at O2 or M3) and for change in weight (kg) between time 1
and time 2 (between O2 and O3 and between M3 and M4) (see Figure 4.7).
The PCS and MCS scores differed significantly across physical activity change categories (p < .001).
Among the three groups of women whose physical activity category did not change in the three year
period (consistently sedentary, consistently low active and consistently active), PCS and MCS scores
were significantly lower in women who were consistently sedentary than in those who were
consistently active (see Figure 4.8). This was not surprising. However, mean PCS and MCS scores for
women who were consistently low active (i.e. not meeting the guidelines of 30 minutes of moderate
activity on most days each week) were not significantly different from those of the consistently active
women. This finding confirms findings reported earlier in this report that low levels of physical activity
(ie at a level lower than the current guidelines suggest) are associated with benefits in terms of health
and well-being.
In both cohorts, and for both PCS and MCS, mean scores for the physical activity decreasers were not
significantly different from those of the women in the consistently sedentary category. This finding
supports the strong relationships (reported in Section 3.6 of this report) between physical activity
change and serious illness or major surgery, especially in the older cohort.
Importantly, both mean PCS and mean MCS scores for women whose physical activity increased
during these three year periods were as high for the women who remained consistently active. (This
increasers group included women whose physical activity increased from none to low, as well as those
who increased from the low to the active category; see Figure 3.7). These findings provide strong
support for the notion that it is never too late to increase physical activity levels for improved health
outcomes.
112
Figure 4.7 Mean (and 95% CI) PCS (left hand side) and MCS (right hand side) scores for each physical activity change category in (a) the mid-age women (M3 to M4; N=8,437) and (b) the older women (O2 to 03; N=5,416).
40
42
44
46
48
50
52
54
Cons
iste
ntly
sede
ntar
y
Cons
iste
ntly
Low
Act
ive
Cons
iste
ntly
Hig
h Ac
tive
Dec
reas
e
Incr
ease
Cons
iste
ntly
sede
ntar
y
Cons
iste
ntly
Low
Act
ive
Cons
iste
ntly
Hig
h Ac
tive
Dec
reas
e
Incr
ease
(a) Mid-age women
40
42
44
46
48
50
52
54
Cons
iste
ntly
sede
ntar
y
Cons
iste
ntly
Low
Act
ive
Cons
iste
ntly
Hig
h Ac
tive
Dec
reas
e
Incr
ease
Cons
iste
ntly
sede
ntar
y
Cons
iste
ntly
Low
Act
ive
Cons
iste
ntly
Hig
h Ac
tive
Dec
reas
e
Incr
ease
(b) Older women
Adjusted for BMI, smoking, alcohol, education, country of birth (at baseline or at O2 or M3) and for change in weight (kg) between time 1 and time 2 (between O2 and O3 and between M3 and M4). All scores are standardised to the norms for the Australian population (mid-age PCS=48.4528; older PCS=51.4080; mid-age MCS=48.4870; older
Relationships Between Physical Activity and Selected Health Outcomes
113
Physical Activity and Health in Mid-Age and Older Women
4.8 Is There any Relationship Between Physical Activity and Health Care Costs in Mid-Age And Older Women?
In 1999 physical inactivity was identified as the leading contributor to the overall burden of disease in
Australian women, and second only to tobacco smoking in men (Mathers, Vos, & Stevenson, 1999).
Indeed, inactivity is independently associated with many chronic health problems, as described in part
one of this report, and exacerbates the metabolic, structural and functional declines of ageing (Singh,
2002). In 2002 the annual direct health care costs of inactivity-related health problems in Australia
were conservatively estimated to be AUD 377 million per year (Stephenson, Bauman, Armstrong,
Smith, & Bellew, 2000). In the US, health care costs have been shown to be inversely associated with
physical activity, after adjustment for body mass index (Wang, McDonald, Reffott, & Edington, 2005),
and it is estimated that individual health care costs are USD300 per year less in regularly active than in
sedentary adults (Pratt, Macera, Wang, 2000).
The aim of the final analysis in this report was to quantify the relationships between physical activity
and Medicare costs in the mid-age and older cohorts of the ALSWH, using data from M3 and O2.
Data from women who responded to either M3 (2001) or O2 (1999), and who gave permission for
linkage to the Medicare data-base (see below) were included in these analyses. Data from women
who reported being unable to walk 100m, with BMI<18.5, or with missing data for one or more of the
weight, height, body mass index or physical activity variables, were excluded, leaving data from 7,004
mid-age and 5,161 older women in the analysis sample.
In Australia, the universal health insurance system, Medicare, covers all permanent residents,
regardless of age or circumstances, for medical services including general practitioner (GP) and
specialist consultations, pathology and radiology and limited additional primary health care services.
Medicare provides a fixed rebate of 85% of the fee set by the government for services provided out-
of-hospital, or 75% for services provided in hospital for private patients. There is no legislation
restricting the amount that doctors can charge for services.
All the women whose data are included in these analyses gave written consent for the release of
Medicare claims data to the research team. Total costs for Medicare-subsidised health services were
recorded for each woman; these cover costs to both the government (the rebate) and the additional
charge paid by the patient. Pharmaceutical and hospital services are not covered by Medicare and
were not available for inclusion in these analyses.
114
Mean annual costs of Medicare reimbursable services for women in each physical activity category
were calculated (2001 costs were used for the mid-age women, and 1999 costs for the older women;
see Figure 4.8). Although the older women made approximately 60% more claims than the mid-age
women, costs were only about 30% more, because many older women were charged only the
Medicare rebateable fee (ie the cost per service was lower than for the mid-age women). Fewer than
10% of the mid-age women and 2% of the older women did not visit a GP; and fewer than 5% and
1% respectively made no claims and therefore had no costs.
The greatest differences in costs were between the none and very low physical activity categories,
indicating that even low levels of physical activity (less than meeting the national guidelines) are
associated with lower health care costs. For the mid-age women mean costs were 26.3% ($134 per
annum) higher in those in the none category than in moderately active women. For older women
mean costs were 23.5% ($156 per annum) higher in the sedentary women
The Medicare costs reported here (an average of $536 and $715 for the mid-age and older women
respectively) include only the costs of visits to general practitioners, medical specialists and outpatient
pathology and radiology services. As such, they represent only a fraction of total health care costs,
which were estimated to be AUD3,931 per person per annum in 2003/04 (Australian Institute of Health
and Welfare, 2005). We did not have access to the costs of hospital services or pharmaceuticals,
which make up the bulk of health care costs in Australia. Similarly, the costs reported here do not
include the costs of work days lost due the chronic health problems that are associated with both
inactivity and overweight.
Although it is not possible to directly compare the costs reported here with those reported in studies
from other countries, it is possible to compare the relative differences reported for health care costs of
people in different physical activity categories (26.3% more in sedentary than in moderately active
mid-age women and 23.5% more for corresponding categories in older women). These percentage
differences are similar to those reported by Pronk, Goodman, O'Connor, & Martinson (1999) for a
sample of participants (40 years or older) in a Minnesota health plan. In that study each additional
active day each week (defined as any activity reported that day) was associated with a 4.7% reduction
in costs (ie a 23.5% reduction for those routinely active on 5 days each week), compared with those
who reported no days of physical activity (Pronk et al., 1999). Another US study, which included all
health care and pharmaceutical costs incurred by a large sample (N=196,000) of employees in the
automotive industry, also found a 23.7% decrease in costs among those who reported brisk physical
activity 3 times a week or more, compared with those who reported none, with an average per person
difference in costs of USD 514 (Wang, McDonald, Champagne, & Edington, 2004). Estimates made by
Pratt, Macera, & Wang (2000) using data from a national sample of US adults in 1987 were somewhat
higher. They estimated that the mean net annual benefit of regular physical activity was USD 330 per
person, or a reduction in costs of 32.4%.
Relationships Between Physical Activity and Selected Health Outcomes
115
Physical Activity and Health in Mid-Age and Older Women
Figure 4.8 Mean annual costs of Medicare rebateable health services by physical activity category for mid-age women in 2001 (pale bars, N=7,204; M3 survey) and older women in 1999 (darker bars, N=4161; O2 survey).
0
100
200
300
400
500
600
700
800
900
none very low low moderate high
annu
al c
ost
mid-aged (2001) older (1999)
116
Additional analyses using these data found that the expected cost savings of activating the most
sedentary women would be greater than those from reducing body mass index. The three-way
relationships between physical activity, body mass index, and health service costs were interesting, as
they showed that costs were not significantly increased in overweight (BMI 25 to <30) mid-age or
older women who reported sufficient physical activity to meet the national guidelines, compared with
healthy weight active women. Regardless of body mass index category, the highest costs were seen
in the women who reported no physical activity.
On a population basis, it is clear from our findings that the greatest relative cost savings could accrue
if sedentary women could improve both their physical activity and body mass index. However, in light
of the fact that many women have difficulty changing their weight, and that there would be significant
cost savings from increasing only physical activity (in sedentary women), our advice would be to
encourage women to focus on increasing physical activity rather than only on losing weight.
Significant benefits in terms of health care costs, both for women and for Medicare, may result if all
women could achieve just 60-150 minutes of moderate intensity physical activity each week (our low
category). In other words, sedentary women would have to walk briskly for 12-30 minutes on five
days each week. Small changes in social support, as well as in workplace, transport and safety
policies, would help these women to achieve this modest goal.
Relationships Between Physical Activity and Selected Health Outcomes
117
Physical Activity and Health in Mid-Age and Older Women
4.9 Discussion
These new data from the Australian Longitudinal Study on Women's Health add to the evidence which
supports our understanding of the relationships between physical activity and specific health outcomes
in mid-age and older women.
Our analyses did not show any relationships between physical activity and menopausal symptoms, or
between physical activity and the development of new arthritis symptoms or arthritis in mid-age
women. Previous findings have shown equivocal findings on the relationship between activity and
both menopausal symptoms and the onset of arthritis in mid-age women.
However, among the older women, the findings confirm those reported in Part Two of this report,
which suggest that levels of physical activity lower than those recommended in the current guidelines
may be protective against the development of some health problems. For example, 75+ minutes of
moderate-intensity physical activity/week was protective against the onset of stiff or painful joints and
even lower levels of activity showed benefits in terms of lower anxiety and depression scores in the
older women.
In contrast, over a three year period, higher levels of physical activity were protective against the
onset of arthritis, and were associated with reduced risk of falls and of broken or fractured bones in
older women who had not had a recent adverse life event or previous serious fall injury. We were not
able to confirm the Framingham finding of increased risk of arthritis with higher levels of physical
activity in the older women (Felsen et al, 1997).
These data confirm the hypothesis raised in Section 2 of this report, that the 'dose' of physical activity
required for the primary prevention of health problems in mid- and older-age women, may not be the
same for every health problem.
Overall, our findings showed that general physical and psychological well-being were significantly
higher in mid-age and older women who were consistently active (ie meeting guidelines) than in those
who were consistently sedentary. This is not surprising. Mean scores for physical and mental well-
being were, however, also significantly higher in mid-age and older women who were consistently 'low'
active (ie reporting 75-150 minutes a week) than in those who were consistently sedentary, suggesting
that, for mid-age and older women, there may be benefits even from low levels of physical activity. In
other words, doing something is better than doing nothing.
118
Another unexpected finding was that levels of physical and mental well-being were as high among
women whose physical activity increased over time (from any baseline level), as they were among the
women who were consistently active. This indicates that, for mid-age and older women, it is never too
late to increase physical activity in order to gain health benefit.
The ALSWH data were also used to show, for the first time in Australia, that physical activity is
inversely associated with healthcare costs in both mid-age and older women. In both the mid-age and
older cohorts health care costs were increased by about one quarter in the sedentary women. As the
greatest differences were seen between sedentary women and those doing low levels of activity, it is
hypothesised that there could be significant cost savings for both women and the health care system if
all sedentary mid-age and older women could be persuaded to do as little as 75 minutes of moderate
intensity physical activity each week.
Relationships Between Physical Activity and Selected Health Outcomes
119
Physical Activity and Health in Mid-Age and Older Women
KEY ISSUES
Women who are consistently active (even at low levels) have better
general physical and psychological well-being than in those who are
consistently sedentary.
Women who increase their physical activity (from any level) have
similar levels of physical and mental well-beingto those women who
are consistently active.
The dose of physical activity required for the primary prevention of
health problems may not be the same for every health problem.
Low levels of physical activity (eg 60-75 minutes/week) can protect
against some health problems, such as stiff or painful joints and
anxiety/depression.
Higher levels of physical activity (>75 minutes/week) are protective
against the onset of arthritis, and reduce the risk of falls and
fractures.
Physical activity is inversely associated with healthcare costs in both
mid-age and older women.
Healthcare costs are about 25% higher in sedentary women than in
active women.
120
If sedentary mid-age and older women increased their physical
activity to 75-150 minutes/week of moderate intensity physical
activity, this would provide significant health benefits and healthcare
cost savings.
Doing some physical activity is better than doing none.
It's never too late to increase physical activity for improved health
and well-being.
121
REFERENCES
Access Economics. Arthritis - The Bottom Line: The Economic Impact of Arthritis in Australia.
Sydney, Arthritis Australia, 2005.
Aiello EJ, Yutaka Y, Tworoger SS, Ulrich CM, Irwin ML, Bowen D, Schwartz RS, Kumai C, Potter JD,
McTiernan A. Effect of a yearlong, moderate-intensity exercise intervention on the occurrence and
severity of menopause symptoms in postmenopausal women. Menopause, 2004; 11: 283-288.
Ainsworth BE. Issues in the assessment of physical activity in women. Research Quarterly for
Exercise & Sport, 2000; 71(2): 37-42.
Albrand G, Munoz F, Sornay-Rendu E, duBoeuf F, Delmas PD. Independent predictors of all
osteoporosis-related fractures in healthy post menopausal women: the OFELY Study. Bone, 2003;
32: 78-85.
Anderson JP, Ross JA, Folsom AR. Anthropormetric variables, physical activity and incidence of
ovarian cancer. The Iowa Women's Health Study. Cancer, 2004; 100: 1515-21.
Armstrong T, Bauman A, Davies J. Physical activity patterns of Australian adults. Results of the
1999 National physical activity survey. Canberra: Australian Institute of Health and Welfare, 2000.
Arthritis Foundation: Exercise and arthritis. Retrieved January 10, 2005, from
http://www.arthritis.org/conditions/exercise/default.asp.
Australian Bureau of Statistics. Australian standard classification of occupations (ASCO). Catalogue
No. 122.0. Canberra: Australian Bureau of Statistics, 1986.
Australian Bureau of Statistics. Cancer in Australia: a Snapshot 2001. Retrieved February 20 2006
from
http://www.abs.gov.au/Ausstats/[email protected]/0/8ddd5aed085834daca256f010077be4a?OpenDocume
nt
Australian Institute of Health and Welfare: Health system expenditure on disease and injury in
Australia, 2000-2001. AIHW Cat No HWE 26. 2004.
Australian Institute of Health and Welfare. Australia’s health 2004. Canberra: Australian Institute
of Health and Welfare, 2004.
Australian Institute of Health and Welfare (AIHW). Health expenditure Australia 2003-4. AIHW
Cat. No. HWE 32 (Health and Welfare Expenditure Series No. 25). Canberra: AIHW. 2005.
122
Australian Institute of Health and Welfare. Australia's health 2006. AIHW cat. No. 73. Canberra:
AIHW, 2006.
Bailey D. Is anyone out there listening? Quest, 2000; 52: 344-50.
Batty GD. Physical activity and coronary heart disease in older adults. A systematic review of
epidemiological studies. European Journal of Public Health, 2002; 12: 171-6.
Bauman, AE. Updating the evidence that physical activity is good for health: an epidemiologic
review 2000-2003. Journal of Science and Medicine in Sport, 2004; 7(1): 6-19.
Bauman A, Merom D. Measurement and surveillance of physical activity in Australia - an
introductory guide. Australasian Epidemiologist, 2002; 9(2): 2-6.
Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to
the emergency department after a fall: a retrospective analysis. Medical Journal Australia, 2000,
173, 179-182.
Berg G, Gottwall T, Hammar M, Lindgren R. Climacteric symptoms among women aged 60–62 in
Linköping,Sweden, in 1986. Maturitas, 1988; 10: 193–9.
Bertone ER, Willett WC, Rosner BA, Hunter DJ, Fuchs CS, Speizer FE, Colditz GA, Hankinson SE.
Prospective study of recreational physical activity cancer and ovarian cancer. Journal of the
National Cancer Institute, 2001; 93(12): 942-8.
Bittman M. Juggling time. How Australians families use time. Canberra: Commonwealth of
Australia, 1991.
Blair SN, Connelly JC. How much physical activity should we do? The case for moderate amounts
and intensities of physical activity. Research Quarterly for Exercise and Sport, 1996; 67(2): 193-
205.
Booth, M. L., Bauman, A., Owen, N., & Gore, C. J. (1997). Physical activity preferences, preferred
sources of assistance, and perceived barriers to increased activity among physically inactive
Australians. Preventive Medicine, 26(1), 131-137.
Brown WJ. The benefits of physical activity during pregnancy. Journal of Science & Medicine in
Sport, 2002; 5(1): 37-45.
Brown WJ, Bryson L, Byles JE, Dobson AJ, Lee C, Mishra G, Schofield M. Women's Health
Australia: recruitment for a national longitudinal cohort study. Women & Health, 1998; 28(1): 23-
40.
Brown WJ, Ford JH, Burton NW, Marshall AL, Dobson AJ. Prospective study of physical activity and
depressive symptoms in middle-aged women. American Journal of Preventive Medicine, 2005;
29(4): 265-72.
123
Brown WJ, Mishra G Lee C & Bauman A. Leisure time physical activity in Australian women:
relationship with well-being and symptoms. Research Quarterly for Exercise and Sport; 2000; 71
(3): 206-216.
Brown WJ, Trost SG. Life transitions and changing physical activity patterns in young women.
American Journal of Preventive Medicine; 2003; 25(2): 140-143.
Brown WJ, Trost SG, Baumann A, Mummery K, Owen N. Test-retest reliability of four physical
activity measures used in population surveys. Journal of Science & Medicine in Sport, 2004;
36:1181-6.
Brown WJ, Trost SG, Ringuet C, Jenkins D. (2001). Measurement of energy expenditure of daily
tasks among mothers of young children. Journal of Science & Medicine in Sport; 4(4): 379-385.
Brown W, Williams J, Ford J, Ball K, Dobson A. Identifying the 'energy gap': magnitude and
determinants of five year weight gain in mid-age women. Obesity Research, 2005; 13(8), 1431-
41.
Brukner P, Brown WJ. Is exercise good for you? Medical Journal of Australia, 2005; 183; 538-41.
Buring JE, Hennekens CH. The Women's Health Study: summary of the study design. Journal of
Myocardial Ischaemia, 1992a, 4: 27-29.
Buring JE, Hennekens CH. The Women's Health Study: rationale and background. Journal of
Myocardial Ischaemia, 1992b, 4: 30-40.
Byles J, Feldman S, Dobson A. The art of ageing as an older widowed woman in Australia. In S.
Carmel, C. Morse, F. Torres-Gil (Eds.), Lessons on aging from three nations, Volume I: The art of
aging well. Baywood Publishing Company, Inc: New York, 2006.
Camacho TC, Roberts RE, Lazarus NB, Kaplan GA, Cohen RD. Physical activity and depression:
evidence from the Alameda County Study. American Journal of Epidemiology, 1991; 134: 220-31.
Centers for Disease Control and Prevention. Prevalence of arthritis--United States, 1997. MMWR,
2001, 50:334-336.
Chao A, Connell CJ, Jacobs EJ, McCullough ML, Patel AV, Calle EE, Cokkinides VE, Thun MJ.
Amount, type, and timing of recreational physical activity in relation to colon and rectal cancer in
older adults: the Cancer Prevention Study II Nutrition Cohort. Cancer Epidemiology, Biomarkers &
Prevention, 2003; 13(12): 2187-95.
Chapurlat RD, Bauer DC, Nevitt M, Stone K, Cummings SR. Incidence and risk factors for a second
hip fracture in elderly women. The Study of Osteoporotic Fractures. Osteoporosis International,
2003; 14: 130-6.
124
Cheung NW, Byth K. Population health significance of gestational diabetes. Diabetes Care, 2003;
27(7): 2005-9.
Cheng Y, Macera CA, Davis DR, Ainsworth BE, Troped PJ, Blair SN. Physical activity and self
reported, physician diagnosed osteoarthritis: is physical activity a risk factor? Journal of Clinical
Epidemiology, 2000; 53: 315-322.
Colditz GA, Cannuscio CC, Frazier AL. Physical activity and reduced risk of colon cancer:
implications for prevention. Cancer Causes and Control, 1997; 8: 649-67.
Colditz GA, Hankinson SE. The nurses' health study: lifestyle and health among women. Nature
Reviews Cancer, 2005; 5: 388-96.
Comijs HC, Deeg DJH, Dik MG, Twisk JWR, Jonker C. Memory complaints; the association with
psycho-affective and health problems and the role of personality characteristics. A 6-year follow-
up. Journal of Affective Disorders, 2002; 72: 157-165.
Commonwealth Department of Health and Aged Care. National physical activity guidelines for
Australians. Canberra: Department of Health and Aged Care, 1999.
Critchley JA, Capewell S. Prospective cohort studies of coronary heart disease in the UK: a
systematic review of past, present, and planned studies. Journal of Cardiovascular Risk, 2003;
10(3): 111-9.
Crook TH, Feher EP, Larrabee GJ. Assessment of memory complaint in age-associated memory
impairment: The MAC-Q. International Psychogeriatrics, 1992; 4(2), 165-176.
Dempsey JC, Sorensen TK, Willaims MA, Lee IM, Miller RS, Dashow EE, Luthy DA. Prosepctive
study of gestational diabetes mellitus risk in relation to maternal recreational physical activity
before and during pregnancy. American Journal of Epidemiology, 2004; 159: 663-70.
Dennerstein L, Dudley E, Guthrie J, Barrett-Connor E. Life satisfaction, symptoms, and the
menopausal transition. Medscape Women's Health, 2000; 5(4): E4.
Department of Human Services and Health. Rural, remote and metropolitan areas of classification
1991 Census edition. Canberra: Australian Government Publishing Service; 1994.
Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age Ageing, 1999; 28:
121-125.
Dorn JP, Cerny FJ, Epstein H, Naughton J, Vena JE, Winkelstein W, Schisterman E, Trevisan M.
Work and leisure time physical activity and mortality in men and women from a general population
sample. Annals of Epidemiology, 1999; 9: 366-73.
125
Dotevall A, Johansson S, Wihelmsen L, Rosengren A. Increased levels of triglycerides, BMI and
blood pressure and low physical activity increase the risk of diabetes in Swedish women. A
prospective 18 year follow up of the BEDA study. Diabetic Medicine, 2004; 21: 615-22.
Drinkwater BL. Exercise in the prevention of osteoporosis. Osteoporosis International, 1993;
S169-171.
Dudley EC, Hopper JL, Taffe J, Guthrie JR, Burger HG, Dennerstein L. Using longitudinal data to
define the perimenopause by menstrual cycle characteristics. Climacteric, 1998; 1: 18–25.
Dunn A, Trivedi M, O'Neal H. Physical activity dose-response effects on outcomes of depression
and anxiety. Medicine and Science in Sports and Exercise, 2001; 33(6 Suppl), S587-597.
Dye TD, Knox KL, Artal R, Aubry RH, Wojtowycz MA. Physical activity, obesity, and diabetes in
pregnancy. American Journal of Epidemiology, 1997; 146(11): 961-5.
Ellekjaer H, Holman J, Ellekjar E, Vatten L. Physical activity and stroke mortality in women: ten
year follow up of the Nord-Trondelag Health Survey 1984-1986. Stroke, 2000; 31: 14-18.
Ekelund LG, Haskell WL, Johnson JL, Whaley FS, Criqui MH, & Sheps DS. Physical fitness as a
predictor of cardiovascular mortality in asymptomatic North American men: The Lipid Research
Clinics Mortality Follow-up Study. New England Journal of Medicine, 1988; 319: 1379-84.
Eyler AA, Matson-Koffman D, Vest JR, Evenson KR, Sanderson B, Thompson JL, et al.
Environmental, policy, and cultural factors related to physical activity in a diverse sample of
women: The Women's Cardiovascular Health Network Project - Summary and discussion. Women
and Health, 2002; 36(2): 123-134.
Faber MJ, Bosscher RJ, Chin APM, van Wieringen PC. Effects of exercise programs on falls and
mobility in frail and pre-frail older adults: A multicenter randomized controlled trial. Archives of
Physical and Medical Rehabilitation, 2006; 87: 885-896.
Farmer, ME, Locke BZ, Moscicki EK, Dannenberg AL, Larson, DB, Radloff LS. Physical activity and
depressive symptoms: the NHANES I epidemiologic follow-up Study. American Journal of
Epidemiology, 1988; 128: 1340-1351.
Farrell SW, Braun L, Barlow CE, Cheng YJ, Blair SN. The relation of body mass index,
cardiorespiratory fitness and all cause mortality in women. Obesity Research, 2002; 1096: 417-23.
Felson DT, Zhang Y, Hannan MT, Naimark A, Weissman B, Aliabadi P, Levy D. Risk factors for
incident radiographic knee osteoarthritis in the elderly. The Framingham Study. Arthritis and
Rheumatism, 1997; 40(4): 728-33.
Feskanich D, Willett WC, Colditz GA. Walking and leisure time physical activity and risk of hip
fracture in post menopausal women. JAMA, 2002; 288(18): 2300-06.
126
Folsom AR, Arnett DK, Hutchison RG, Liao F, Clegg LX, Cooper LS. Physical activity and incidence
of coronary heart disease in middle aged women and men. Medicine and Science in Sports and
Exercise, 1997; 29(7): 901-9.
Folsom AR, Kushi LH, Hong CP. Physical activity and incident diabetes mellitus in post menopausal
women. American Journal of Public Health, 2000; 90(1): 134-8.
Fox KR. Physical activity and mental health promotion: the natural partnership. International
Journal of Mental Health Promotion, 2000; 2(1): 4-12.
Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for
preventing falls in elderly people. Cochrane Database Systematic Reviews, 2006; CD000340.
Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer M, & Willett WC. Physical activity,
obesity, and risk for colon cancer and adenoma in men. Annals of Internal Medicine, 1995; 122:
327-34.
Golomb LM, Solidum AA, Warren MP. Primary dysmenorrheal and physical activity. Medicine and
Science in Sports and Exercise, 1998; 30(6): 906-9.
Gregg EW, Cauley JA, Seeley DG, Ensrud KE, Bauer DC. Physical activity and osteoporotic fracture
risk in older women. Annals of Internal Medicine, 1998; 129(2): 81-88.
Gregg EW, Cauley JA, Stone K, Thompson TJ, Bauer DC, Cummings SR, Ensrud KE, for the Study
of Osteoporotic Fractures Research Group. Relationship of changes in physical activity and
mortality among older women. JAMA, 2003; 289(18): 2379 – 2386.
Greene JG. Constructing a standard climacteric scale. Maturitas, 1998; 29: 25–31.
Guthrie JR, Dennerstein L, Taffe JR, Lehert P, Burger HG. Hot flushes during the menopause
transition: a longitudinal study in Australian-born women. Menopause, 2003; 12(4): 460-7.
Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. Association of leisure time physical activity
with the risk of coronary heart disease, hypertension, and diabetes in middle aged men and
women. International Journal of Epidemiology, 1997; 26(4): 739 – 47.
Haapanen-Niemi N, Miilunpalo S, Pasanen M, Vuori I, Oja P, Malmberg J. Body mass index,
physical inactivity and low level of physical fitness as determinants of all cause and cardiovascular
disease mortality – 16 year follow up of middle aged and elderly men and women. International
Journal of Obesity, 2000; 24: 1465-1474.
Hardman AE. Issues of fractionalization of exercise (short vs long bouts). Medicine and Science in
Sports and Exercise, 2001; 33(6 Suppl): S421-7.
Hart DJ, Doyle DV, Spector TD. Incidence and risk factors for radiographic knee osteoarthritis in
middle aged women. Arthritis and Rheumatism, 1999; 42 (1): 17-24.
127
Hatch M, Levin B, Shu XO, Susser M. Maternal leisure time exercise and timely delivery. American
Journal of Public Health, 1998, 88(10): 1528-33.
Headey B, Warren D, Harding G. Families, Incomes and Jobs: A Statistical Report of the HILDA
Survey. Melbourne Institute if Applied Economic and Social Research, The University of
Melbourne, 2006.
Hebert R, Lindsay J, Verreault R, Rockwood K, Hill G, DuBois M. Vascular dementia: Incidence and
risk factors in the Canadian Study of Health and Aging. Stroke, 2000; 31(7): 1487-93.
Heesch KC, Miller YD, Brown, WJ. Relationship between physical activity and stiff or painful joints
in mid-aged and older women: A 3 year prospective study. Arthritis Research & Therapy. 2007;
9:R34. http://arthritis-research.com/content/9/2/R34
Hill K, Schwarz J, Flicker L, Carroll S. Falls among healthy, community-dwelling, older women: a
prospective study of frequency, circumstances, consequences and prediction accuracy. Australia
and New Zealand Journal of Public Health, 1999; 23: 41-48.
Hootman JM, Macera CA, Helmick MD, Blair SN. Influence of physical activity related joint stress
on the risk of self reported hip/knee osteoarthritis: a new method to quantify physical activity.
Preventive Medicine, 2003; 36: 636-44.
Hsia J, Wu L, Allen C, Oberman A, Lawson WE, Torrens J, Safford M, Limacher MC, Howard BV,
Women's Health Research Group. Physical activity and diabetes risk in post menopausal women.
American Journal of Preventive Medicine, 2005; 28(1): 19-25.
Hu FB, Li TY, Colditz GA, Willett WC, Manson JE. Television watching and other sedentary
behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA, 2003;
289(14): 1785-91.
Hu FB, Sigal RJ, Rich-Edwards JW, Colditz GA, Solomon CG, Willett WC, Speizer FE, Manson JE.
Walking compared with vigorous physical activity and risk of type 2 diabetes in women. JAMA,
1999; 282(15): 1433-39.
Hu FB, Stampfer MJ, Colditz GA, Ascherio A, Rexrode KM, Willett WC, Manson JE. Physical activity
and risk stroke in women. JAMA, 2000; 283(22): 2961-7.
Hundrup YA, Ekholm O, Hoidrup, Davidsen M, Obel EB. Risk factors for hip fracture and a possible
effect modification by hormone replacement therapy. The Danish Nurse Cohort Study. European
Journal of Epidemiology, 2005; 20: 871-7.
Ivers RQ, Cumming RG, Mitchell P, Peduto AJ. Risk factors for fractures of the wrist, shoulder, and
ankle: The Blue Mountains Eye Study. Osteoporosis International, 2002; 13: 513-8.
128
Jakicic JM, Marcus BH, Gallagher KI, Napolitano M, Lang W. Effect of exercise duration and
intensity on weight loss in overweight, sedentary women: a randomized trial. JAMA, 2003;
290(10): 1323-30.
Jiang H, Ogden LG, Bazzano LA, Vupputuri S, Loria C, Whelton PK. Risk factors for congestive
heart failure in US men and women: NHANES I epidemiologic follow up study. Archives of Internal
Medicine, 2001; 161(7); 996-1002.
Johansson B, Allen-Burge R, Zarit SH. Self-reports on memory functioning in a longitudinal study of
the oldest old: Relation to current, prospective, and retrospective performance. Journal of
Gerontology: Psychological Sciences, 1997; 52B(3), P139-P146.
Jonker C, Geerlings MI, Schmand B. Are memory complaints predictive for dementia? A review of
clinical and population-based studies. International Journal of Geriatric Psychiatry, 2000; 15: 983-
991.
Jorm AF, Butterworth P, Anstey KJ, Christensen H, Easteal S, Maller J, et al. Memory complaints in
a community sample aged 60-64 years: associations with cognitive functioning, psychiatric
symptoms, medical conditions, APOE genotype, hippocampus and amygdala volumes, and white-
matter hyperintensities. Psychological Medicine, 2004; 34: 1495-1506.
Jungwirth S, Fischer P, Weissgram S, Kirchmeyr W, Bauer P, Tragl KH. Subjective memory
complaints and objective memory impairment in the Vienna-Transdanube Aging Community. JAGS,
2004; 52: 263-268.
Karlsson M. Has exercise an anti-fracture efficacy in women? Scandinavian Journal of Medicine
and Science in Sports, 2000; 14: 2-15.
Karlsson, M. Does exercise reduce the burden of fractures? A review. Acta Orthopaedia
Scandinavia, 2002; 73(6): 691-705.
Karlsson M. Has exercise an antifracture efficacy in women? Scandinavian Journal of Medicine and
Science in Sports, 2004, 14: 2-15.
Kemmler W, Lauber D, Weineck J, Hensen J, Kalender W, Engelke K. Benefits of 2 Years of Intense
Exercise on Bone Density, Physical Fitness, and Blood Lipids in Early Postmenopausal Osteopenic
Women Results of the Erlangen Fitness Osteoporosis Prevention Study (EFOPS). Archives of
Internal Medicine, 2004; 164: 1084-1091.
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM.
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New
England Journal of Medicine, 2002; 346 (6): 393-403.
Kohl HW. Physical activity and cardiovascular disease: evidence for a dose response. Medicine
and Science in Sports and Exercise, 2001; 33(6 Suppl): S472-83.
129
Kriska AM, Saremi A, Hanson RL, Bennett PH, Kobes S, Williams DE, Knowler WC. Physical activity,
obesity, and the incidence of type 2 diabetes in a high risk population. American Journal of
Epidemiology, 2003: 158: 669-75.
Kritz-Silverstein D, Barrett-Connor E, Corbeau C. Cross sectional and prospective study of exercise
and depressed mood in the Elderly. The Rancho Bernardo Study. American Journal of
Epidemiology, 2001; 153(6): 596-603.
Kushi LH, Fee RM, Folsom AR, Mink PJ, Anderson KE, Sellers TA. Physical activity and mortality in
post menopausal women. JAMA, 1997; 277(16): 1287-92.
Larson, E. B., Wang, L., Bowen, J. D., McCormick, W. C., Teri, L., Crane, P., et al. (2006). Exercise
is associated with reduced risk for incident dementia among persons 65 years of age and older.
Annals of Internal Medicine, 144(2), 73-81.
Latham N, Anderson C, Bennett D, Stretton C. Progressive resistance strength training for physical
disability in older people. Cochrane Database Systematic Reviews, 2003: CD002759.
Laurin D, Verreault R, Lindsay J, MacPherson K, Rockwood K. Physical activity and risk of cognitive
impairment and dementia in elderly persons. Archives of Internal Medicine, 2001; 58(3): 498-504.
Lawlor DA, Hopker SH. The effectiveness of exercise as an intervention in the management of
depression: systematic review and meta-regression analysis of randomised controlled trials. British
Medical Journal, 2001; 322(7289), 763-767.
Lee IM. Physical activity and cancer prevention – data from epidemiologic studies. Medicine and
Science in Sports and Exercise, 2003; 35(11):1823-27.
Lee CD, Folsom AR, Blair SN. Physical activity and stroke risk: a meta analysis. Stroke, 2003; 34:
2475-81.
Lee IM, Paffenbarger RS Jr. How much physical activity is optimal for health? Methodological
considerations. Research Quarterly for Exercise and Sport, 1996; 67(2): 206-208.
Lee IM, Paffenbarger RS Jr, Hsieh CC. Time trends in physical activity among college alumni,
1962–1988. American Journal of Epidemiology, 1992; 135: 915–25
Lee IM, Rexrode KM, Cook NR, Hennekens CH, Burting JE. Physical activity and breast cancer risk:
the Women's Health Study (United States). Cancer Causes and Control, 2001; 12(2): 137-45.
Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease
in women: is "no pain, no gain" passé? JAMA, 2001; 285(11): 1447-54.
130
Lee C, Russell A. Effects of physical activity on emotional well being among older Australian
women. Cross sectional and longitudinal analyses. Journal of Psychosomatic Research, 2003; 54:
155-60.
Lee IM, Sesso HD, Oguma Y, Paffenbarger RS Jr. The "weekend warrior" and risk of mortality.
American Journal of Epidemiology, 2004; 160(7): 636-41.
Levy-Cushman, J., & Abeles, N. (1998). Memory complaints in the able elderly. Clinical
Gerontologist, 19(2), 3-24.
Lilley JM, Arie T, Chilvers CE. Accidents involving older people: a review of the literature. Age
Ageing, 1995, 24, 346-365.
Lord SR, Sherrington C, Menz HB. Falls in older people risk factors and strategies for prevention.
Cambridge, UK: Cambridge University Press, 2001.
Lund Nilsen TI, Vatten LJ. Prospective study of colorectal cancer risk and physical activity,
diabetes, blood glucose and BMI: exploring the hyperinsulinaemia hypothesis. British Journal of
Cancer, 2001; 84(3) 417-422.
Luoto R, Latikka P, Pukkala E, Hakulinen T, Vihko V. The effect of physical activity on breast
cancer risk: a cohort study of 30,548 women. European Journal of Epidemiology, 2001; 16:973-
80.
McTiernan A, Kooperberg C, White E, Wilcox S, Coates R, Adams-Campvell LL, Woods N, Ockene J.
Recreational physical activity and the risk of breast cancer in postmenopausal women: The
Women's Health Initiative Cohort Study. JAMA, 2003; 290(10): 1331-6.
Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, Perri MG, Sheps DS,
Pettinger MB, Siscovick DS. Walking compared with vigorous exercise for the prevention of
cardiovascular events in women. The New England Journal of Medicine, 2002; 347(10): 716-25.
Manson JE, Hu FB, Rich-Edwards JW, Colditz GA, Stampfer MJ, Illett WC, Speizer FE, Hennekens
CH. A prospective study ok walking as compared with vigorous exercise in the prevention of
coronary heart disease in women. The New England Journal of Medicine, 1999; 341: 650-8.
Manson JE, Nathan DM, Krolewski AS, Stampfer MJ, Willett WC, & Hennekens CH. A prospective
study of exercise and incidence of diabetes among US male physicians, JAMA, 1992; 268: 63-7.
Manson JE, Rimm EM, Stampfer MJ, Colditz GA, Willett WC, Krolewski AS, Rosner B, Hennekens
CH, Speizer FE. Physical activity and incidence of non-insulin dependent diabetes mellitus in
women. Lancet, 1991; 338: 774-8.
131
Martinez ME, Giovannucci E, Spiegelman D, Hunter DJ, Willett WC, Colditz GA. Leisure time
physical activity, body size, and colon cancer in women. Journal of the National Cancer Institute,
1997; 89(13): 948-55.
Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Report No.: PHE 17.
Australian Institute of Health and Welfare: Canberra 1999.
McVeigh C: Perimenopause: more than hot flushes and night sweats for some Australian women.
Journal of Obstetric Gynecological Neonatal Nursing, 2005, 34:21-27.
Michaud DS, Giovannucci E, Willett WC, Colditz GA, Stampfer MJ, Fuchs CS. Physical activity,
obesity, height, and the risk of pancreatic cancer. JAMA, 2001; 286(8): 921-9.
Misra DP, Strobino DM, Stashinko EE, Nagey DA, Nanda J. Effects of physical activity on pre-term
birth. American Journal of Epidemiology, 1998; 147(7): 628-35.
Moore DB, Folsom AR, Mink PJ, Hong C, Anderson KE, Kushi LH. Physical activity and incidence of
post menopausal breast cancer. Epidemiology, 2000; 11(3): 292-96.
Moradi T, Nyren O, Bergstrom R, Gridley G, Linet M, Wolk A, Dosemeci M, Adami HO. Risk for
endometrial cancer in relation to occupational physical activity: a nationwide cohort study in
Sweden. International Journal of Cancer, 1998; 76: 665-670.
Morris JN, Everitt MG, Pollard R, Chave SPW, Semmence AM. Vigorous exercise in leisure time:
protection against coronary heart disease. Lancet, 1980; 2: 1207–1210.
Morris JN, Kagan A, Pattison DC, Gardner MJ, Raffle PAB. Incidence and prediction of ischemic
heart disease in London busmen. Lancet, 1966; 2: 553-9.
Morss GM, Jordan AN, Skinner JS, Dunn AL, Church TS, et al. Dose-response to exercise in women
aged 45-74 years (DREW): design and rationale. Medicine and Science in Sports and Exercise,
2004; 36: 336-44.
Nakayama T, Date C, Yokoyama T, Yoshiike N, Yamaguchi M, Tanaka H. A 15.5 year follow up of
stroke in a Japanese provincial city. Stroke, 1997; 28: 45-52.
National Heart Foundation. Risk factor prevalence study no. 3. Canberra: National Heart
Foundation, 1989.
O'Sullivan J. Diabetes mellitus after gestational diabetes mellitus. Diabetes, 1991; 29: 131-5.
Paffenbarger RS Jr, Hale WE. Work activity and coronary heart mortality. New England Journal of
Medicine, 1975; 292: 545-50.
132
Paffenbarger RS Jr, Hyde RT, Wing AL. Physical activity and incidence of cancer in diverse
populations: a preliminary report. American Journal of Clinical Nutrition, 1987; 45: 312-7.
Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college
alumni. American Journal of Epidemiology, 1978; 108: 161-75.
Paffenbarger RS Jr, Lee IM, Leung R. Physical activity and personal characteristics associated with
depressions and suicide in American college men. Acta Psychiatrica Scandinavica Supplementum,
1994; 377: 16-22.
Paganini-Hill A, Barreto MP. Stroke risk in older men and women: aspirin, estrogen, exercise,
vitamins and other factors. Journal of Gender Specific Medicine, 2001; 4(2): 18-28.
Paluska SA, Schwenk TL. Physical activity and mental health. Current concepts. Sports Medicine,
2000; 29(3): 167-80.
Pan XR, Li GW, Hu YH,Wang JX, Yang WY, An ZX, Hu ZX, Lin J, Xiao JZ, Cao HB, Liu PA, Jiang XG,
Jiang YY, Wang JP, Zheng H, Zhang H, Bennett PH, Howard BV. Effects of diet and exercise in
preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes
Study. Diabetes Care, 1997; 20(4): 537-44.
Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, et al. Physical activity and public
health - a recommendation from the Centres for Disease Control and Prevention and the American
College of Sports Medicine. Journal of the American Medical Association, 1995; 273(5), 402-7.
Patel AV, Rodriguez C, Bernstein L, Chao A, Thun MJ, Calle EE. Obesity, recreational physical
activity and risk of pancreatic cancer in a large US cohort. Cancer Epidemiology, Biomarkers &
Prevention, 2005; 14(2): 459-66.
Pratt M, Macera C, Wang G. Higher direct medical costs associated with physical inactivity.
Physician Sportsmedicine 2000; 28: 63-70.
Pronk NP, Goodman MJ, O'Connor PJ, Martinson BC. Relationship between modifiable health risks
and short term health care charges. JAMA, 1999; 282:2235-9.
Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease.
Scandinavian Journal of Medicine and Science in Sports, 2006; 16(Suppl 1): 3-63.
Penedo FJ, Dahn JR. Exercise and well-being: a review of mental and physical health benefits
associated with physical activity. Current Opinion in Psychiatry, 2005; 18: 189-93.
Phillips WT, Kirnan M, King AC. Physical activity as a nonpharmacological treatment for
depression: a review. Complementary Health Practice Review, 2003; 8(2): 139-152.
Pignatti F, Rozzini R, Trabucchi M. Physical activity and cognitive decline in elderly persons.
Archives of Internal Medicine, 2002; 162(3): 361.
133
Prime Minister's Science, Engineering and Innovation Council (PMSEIC). Promoting healthy ageing
in Australia. Canberra: Australian Government Publishing Service, 2003.
Riedel-Heller SG, Matschinger H, Schork A, Angermeyer MC. Do memory complaints indicate the
presence of cognitive impairment? Results of a field study. European Archives of Psychiatry and
Clinical Neuroscience, 1999; 249: 197-204.
Rockhill B, Willett WC, Hunter DJ, Manson JE, Hankinson SE, Colditz GA. A prospective study of
recreational physical activity and breast cancer risk. Archives of Internal Medicine, 1999; 159:
2290-96.
Rockhill B, Willett WC, Manson JE, Leitzmann MF, Stampfer MJ, Hunter DJ, Coldtidz GA. Physical
activity and mortality: a prospective study among women. American Journal of Public Health,
2001; 91 (4): 578 – 83.
Rockhill B, Willett WC, Hunter DJ, Manson JE, Hankinson SE, Spiegelman D, Colditz GA. Physical
activity and breast cancer risk in a cohort of young women. Journal of the National Cancer
Institute, 1998; 90(15): 1155-60.
Rose G. The strategy of preventive medicine. New York: Oxford University Press, 1992.
Samad AKA, Taylor RS, Marshall T, Chapman MAS. A meta-analysis of the association of physical
activity with reduced risk of colorectal cancer. Colorectal Disease, 2005; 7: 204-13.
Sattin RW, Lambert Huber DA, Devito CA, Rodriguez JG, Ros A, Bacchelli S, et al. The incidence of
fall injury events among the elderly in a defined population. American Journal of Epidemiology,
1990, 131: 1028-1037.
Schaper AG, Wannamathee G. Physical activity and ischaemic heart disease in middle-aged British
men. British Heart Journal, 1991; 66: 384-94.
Seavey WG, Kurata JH, Cohen RD. Risk factors for incident self-reported arthritis in a 20 year
follow-up of the Alameda County Study Cohort. Journal of Rheumatology, 2003; 30: 2103-11.
Sesso HD, Paffenbarger RS Jr, Lee IM. Physical activity and breast cancer risk in the College
Alumni Health Study (United States). Cancer Causes and Control, 1998; 9: 433-9.
Sesso HD, Paffenbarger RS, Ha T, Lee IM. Physical activity and cardiovascular disease risk in
middle-aged and older women. American Journal of Epidemiology, 1999; 150(4): 408-16.
Sherrington C, Lord SR, Finch CF. Physical activity interventions to prevent falls among older
people: update of the evidence. Journal of Science and Medicine in Sport, 2004; 7: 43-51.
Singh, MAF. Exercise comes of age: rationale and recommendations for a geriatric exercise
prescription. Journal of Gerontology 2002; 57A: M262-82.
134
Sinner PJ, Schmitz KH, Anderson KE, Folsom AR. Lack of association of physical activity and
obesity with incident pancreatic cancer in elderly women. Cancer Epidemiology, Biomarkers &
Prevention, 2005; 14(6): 1571-3.
Slattery ML. How much physical activity do we need to maintain health and prevent disease?
Different diseases – different mechanisms. Research Quarterly in Exercise and Sport, 1996; 67(2):
209-212.
Slaven L, Lee C. Mood and Symptom Reporting Among Middle-Aged Women: The Relationship
Between Menopausal Status, Hormone Replacement Therapy, and Exercise Participation. Health
Psychology, 1997; 16: 203-208.
Slemenda C. Prevention of hip fractures: risk factor modification. American Journal of Medicine,
1997; 103(2A): 65S-73S.
Slentz CA, Dusch BD, Johnson JL, Ketchum K, Aiken LB, Samsa GP, Houmard JA, Bales CW, Kraus
WE. Effects of the amount of exercise on body weight, body composition, and measures of central
obesity: STRRIDE--a randomized controlled study. Archives of Internal Medicine, 2004; 164(1):
31-9.
Solomon CG, Willett WC, Carey VJ, Rich-Edwards J, Huneter DJ, Colditz GA, Stampfer MJ, Speizer
FE, Speigelman D, Manson JE. A prospective study of pregravid determinants of gestational
diabetes mellitus. JAMA, 1997; 278: 1078-1083.
Speechley M, Tinetti M. Falls and injuries in frail and vigorous community elderly persons. Journal
of the American Geriatric Society, 1991; 39: 46-52.
Sports Medicine Australia. SMA statement: the benefits and risks of exercise during pregnancy.
Journal of Science and Medicine in Sport, 2002; 5(1): 11 – 19.
St John, P., & Montgomery, P. (2003). Is subjective memory loss correlated with MMSE scores or
dementia? Journal of Geriatric Psychiatry and Neurology, 16, 80-83.
Stephenson J, Bauman A, Armstrong T, Smith B, Bellew B. The costs of illness attributable to
physical inactivity in Australia: a preliminary study. The Commonwealth Department of Health and
Aged Care and the Australian Sports Commission: Canberra 2000.
Sternfeld B, Jacobs MK, Quesenberry CP Jr, Gold EB, Sowers M. Physical activity and menstrual
cycle characteristics in two prospective cohorts. American Journal of Epidemiology, 2002; 156(5):
402-9.
Suutama T, Ruoppila I. Associations between cognitive functioning and physical activity in two 5
year follow up studies of older Finnish persons. Journal of Aging and Physical Activity, 1998; 6:
169-83.
135
Swain, DP & Franklin BA. Comparison of cardioprotective benefits of vigorous versus moderate
intensity aerobic exercise. American Journal of Cardiology, 2006; 97: 141-7.
Taylor HL, Klepetar E, Keys A, Parlin W, Blackburn H, Puchner T. Death rates among physically
active and sedentary employees of the railroad industry. American Journal of Public Health, 1962;
52: 1697 -1707.
Tehard B, Friedenreich CM, Oppert JM, Clavel-Chapelon F. Effect of physical activity on women at
increased risk of breast cancer: results fro the E3N Cohort Study. Cancer Epidemiology,
Biomarkers & Prevention, 2006; 15(1): 57-64.
Terry P, Baron JA, Weiderpass E, Yuen J, Lichtenstein P, Nyren O. Lifestyle and endometrial
cancer risk: a cohort study from the Swedish twin registry. International Journal of Cancer, 1999;
82:38-42.
The Australian Longitudinal Study on Women's Health. Trends in women's health: Results from
the ALSWH – priority conditions, risk factors and health behaviours. Report prepared for the
Australian Government Department of Health & Ageing. March 2006.
Thune I, Brenn T, Lund E, Gaard M. Physical activity and the risk of breast cancer. The New
England Journal of Medicine, 1997; 336(18):1269-75.
Thune I, Lund L. Physical activity and risk of colorectal cancer in men and women. British Journal
of Cancer, 1996; 73: 1134-40.
Thune I, Lund E. The influence of physical activity on lung cancer risk. International Journal of
Cancer, 1997; 70: 57-62.
Tinetti ME. Preventing falls in elderly persons. New England Journal of Medicine, 2003; 348: 42-49.
Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home.
New England Journal of Medicine, 1997; 337, 1279-1284.
Tripathi A, Folsom AR, Anderson KE. Risk factors for urinary baldder carcinoma in post
menopausal women. The Iowa Women's Study. Cancer, 2002; 95: 2316-23.
Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-
Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Aunola S, Cepaitis Z, Moltchanov
V, Hakumaki M, Mannelin M, Martikkala V, Sundvall J, Uusitupa M, for the Finnish Diabetes
Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among
subjects with impaired glucose tolerance. New England Journal of Medicine, 2001; 344(18): 1343-
50.
136
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 Heath Promotion, 1996.
US Department of Health and Human Services and the Department of Agriculture. Dietary
guidelines for Americans 2005. Retrieved February 22, 2006, from
http://www.healthierus.gov./dietaryguidelines/.
Utian WH. Psychosocial and socioeconomic burden of vasomotor symptoms in menopause: A
comprehensive review. Health and Quality of Life Outcomes, 2005, 3:47.
Van Dijk BAC, Schouten LJ, Kiemeney LALM, Goldbohm RA, van den Brandt PA. Relation of height,
body mass, energy intake, and physical activity to risk of renal cell carcinoma: results from the
Netherlands Cohort Study. American Journal of Epidemiology, 2004; 160: 1159-1167.
Wang L, Larson EB, Bowen JD, van Belle G. Performance-based physical function and future
dementia in older people. Archives of Internal Medicine, 2006; 166: 1115-1120.
Wang F, McDonald T, Reffott B, Edington DW. BMI, physical activity and health care
utilization/costs among Medicare retirees. Obesity Research 2005; 13: 1450-7.
Wannamethee SG, Shaper AG. Physical activity and cardiovascular disease. Seminars in Vascular
Medicine, 2002; 2(3): 257-66.
Ware JE, Kosinski M, Keller SD. SF-36 Physical and mental health summary scales: A User's
Manual. Boston, MA: health Assessment Lab, 1994.
Weinstein AR, Sesso HD, Lee IM, Cook NR, Manson JE, Buring JE, Gaziano JM. Relationship of
physical activity vs body mass index with type 2 diabetes in women. JAMA, 2004; 292(10): 1188-
94.
Weller I, Corey P. The impact of excluding non-leisure energy expenditure on the relation between
physical activity and mortality in women. Epidemiology, 1998; 9: 632-5.
Weuve J, Kang JH, Manson JE, Breteler MMB, Ware JH, Grodstein F. Physical activity, including
walking, and cognitive function in older women. JAMA, 2004; 292: 1454-61.
Weyerer S. Physical inactivity and depression in the community: evidence from the Upper Bavarian
Field Study. International Journal of Sports Medicine, 1992; 13: 492-6.
Wilcox S, Parra-Medina D, Thompson-Robinson M, Will J. Nutrition and physical activity
interventions to reduce cardiovascular disease risk in health care settings: a quantitative review
with a focus on women. Nutrition Reviews, 2001; 59(7): 197-215.
Willer A. Reduction of the individual cancer risk by physical exercise. Onkologie, 2003; 26: 283-
289.
137
Wolf AM, Hunter DJ, Colditz GA, Manson JE, Stampfer MJ, Corsano KA, Rosner B, Kriska A, &
Willett WC. Reproducability and validity of a self-administered physical activity questionnaire.
International Journal of Epidemiology, 1994; 23: 991-9.
Yaffe K, Barnes D, Nevitt M, Lui LY, Covinsky K. A prospective study of physical activity and
cognitive decline in elderly women. Archives of Internal Medicine, 2001; 161: 1703-8.
138
139
APPENDICES
140
AP
PEN
DIX
A
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Coro
nary
Hea
rt D
isea
se/C
ardi
ovas
cula
r D
isea
se.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Dor
n et
al.,
(1
999)
Bu
ffal
o H
ealth
St
udy
(USA
) N
=76
3 15
-96
year
s of
ag
e in
196
0
Inte
rvie
w:
196
0-61
�
Num
ber
of w
orkd
ay h
ours
si
ttin
g, s
tand
ing,
car
ryin
g or
lif
ting
obje
cts
>25
pou
nds,
di
ggin
g, w
ork
exer
cise
ac
tiviti
es, s
leep
ing
�
Num
ber
of b
lock
s w
alke
d du
ring
wor
kday
�
Num
ber
of w
eeke
nd h
ours
si
ttin
g, ly
ing
dow
n,
stan
ding
, spo
rts,
exe
rcis
e su
ch a
s ga
rden
ing
�
Num
ber
of b
lock
s w
alke
d (w
eeke
nd d
ay)
�To
tal P
A en
ergy
exp
endi
ture
(k
cal/k
g/ho
ur)
Coro
nary
hea
rt d
isea
se
mor
talit
y 29
yea
rs
Age,
edu
catio
n, c
igar
ette
s, B
P
For
each
uni
t in
crea
se in
tot
al P
A en
ergy
ex
pend
iture
(kc
al/k
g/ho
ur)
Aged
<60
yea
rs (
n=61
3)
0.42
(0.
11-1
.52)
Ag
ed >
60 y
ears
(n=
150)
1.
78 (
0.77
–4.0
9)
Elle
kjae
r et
al
., (2
000)
N
ord-
Tron
dela
g H
ealth
Sur
vey
(Nor
way
) N
=14
,101
Que
stio
nnai
re:
1984
-6
�W
eekl
y fr
eque
ncy
of
exer
cise
(in
clud
ing
wal
king
) �
Inte
nsity
of
exer
cise
�
Dur
atio
n of
eac
h ex
erci
se
sess
ion
Stro
ke m
orta
lity
10 y
ears
PA le
vel,
all w
omen
Lo
w
1.
00
Med
ium
0.77
(0.
61-0
.98)
H
igh
0.
52 (
0.30
-0.7
2)
p tr
end=
0.00
01
141
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
50-6
9 ye
ars
of
age
(n=
9,46
0)
70-7
9 ye
ars
of
age
(n=
3,41
7)
80-1
01 y
ears
of
age
(n=
1,22
4)
�PA
leve
l: lo
w (
<1x
/wee
k),
med
ium
(<
med
ian)
, hig
h (>
med
ian)
ge, s
mok
ing,
dia
bete
s, B
MI,
an
tihyp
erte
nsiv
e m
edic
atio
n,
SBP,
ang
ina
pect
oris
, m
yoca
rdia
l inf
arct
ion,
illn
ess
impa
iring
fun
ctio
n, e
duca
tion
PA le
vel,
50-6
9 ye
ars
Lo
w
1.
00
Med
ium
0.
57 (
0.34
-0.9
5)
Hig
h
0.42
(0.
24-0
.75)
p
tren
d=0.
0021
PA
leve
l, 70
-79
year
s Lo
w
1.
00
Med
ium
0.
79 (
0.55
-1.1
2)
Hig
h
0.56
(0.
36-0
.88)
p
tren
d=0.
0093
PA
leve
l, 80
-101
yea
rs
Low
1.00
M
ediu
m
0.91
(0.
60-1
.39)
H
igh
0.
57 (
0.30
-1.0
9)
p tr
end=
0.10
8
142
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Fols
om, e
t al
., (1
997)
At
hero
scle
rosi
s Ri
sk in
Co
mm
uniti
es
Stud
y (U
SA).
N
=7,
852
45-6
4 ye
ars
of
age
Inte
rvie
w:
1987
-89
Spor
ts P
A in
pas
t ye
ar
�Fr
eque
ncy,
dur
atio
n,
inte
nsity
�
Freq
uenc
y of
sw
eatin
g,
play
ing
spor
ts, s
elf
com
paris
on w
ith o
ther
s
Leis
ure
PA in
pas
t ye
ar
�Fr
eque
ncy
of t
elev
isio
n,
wal
king
, cyc
ling,
w
alki
ng/c
yclin
g to
w
ork/
shop
ping
Q
uart
iles
(val
ues
not
give
n)
�Sp
orts
PA
�Le
isur
e PA
�
Coro
nary
hea
rt d
isea
se
inci
dent
eve
nts
(MI
or d
eath
) 4-
7 ye
ars
Age,
edu
catio
n, s
mok
ing,
al
coho
l, H
RT, r
ace,
stu
dy
cent
re, d
iabe
tes,
wai
st h
ip
ratio
, T-C
, HD
L-C,
SBP
, an
tihyp
erte
nsiv
e m
edic
atio
n,
fibrin
ogen
Spor
ts P
A Lo
wes
t
1.00
2nd
qua
rtile
0.
96 (
0.49
-1.9
2)
3rd q
uart
ile
0.51
(0.
21-1
.21)
H
ighe
st
0.49
(0.
21-1
.31)
p
tren
d=0.
04
Leis
ure
PA
Low
est
1.
00
2nd q
uart
ile
0.74
(0.
42-1
.21)
3rd
qua
rtile
1.
07 (
0.55
-2.0
9)
Hig
hest
0.
64 (
0.34
-1.2
4)
p tr
end=
0.37
Gre
gg, e
t al
., (2
003)
St
udy
of
Ost
eopo
rotic
Fr
actu
res
(USA
) N
=7,
553
>65
yea
rs o
f ag
e
Que
stio
nnai
re:
1986
-8, 1
992-
4 �
Freq
uenc
y an
d du
ratio
n of
le
isur
e PA
(in
clud
ing
gard
enin
g) in
pas
t ye
ar
�N
umbe
r ci
ty b
lock
s w
alke
d da
ily
Card
iova
scul
ar d
isea
se
mor
talit
y 12
.5 y
ears
Tota
l PA
(kca
l/wee
k)
<16
3
1.00
16
3-50
3 0.
65 (
0.53
-0.7
9)
504-
1045
0.
70 (
0.57
-0.8
5)
1046
-190
6 0.
60 (
0.48
-0.7
5)
>19
07
0.
58 (
0.46
-0.7
4)
143
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�To
tal P
A en
ergy
exp
endi
ture
qu
intil
es (
kcal
/wee
k)
�W
alki
ng e
nerg
y ex
pend
iture
qu
intil
es (
kcal
/wee
k)
�PA
cha
nge
(198
6-8
and
1992
-4, m
edia
n 5.
7 ye
ars)
:
stay
ed s
eden
tary
(lo
wes
t 40
%, <
595k
cal/w
k),
beca
me
activ
e (m
oved
fro
m
low
est
40%
to
high
est
60%
), b
ecam
e se
dent
ary
(mov
ed fro
m h
ighe
st 6
0%
to lo
wes
t 40
%),
sta
yed
activ
e
Age,
sm
okin
g, B
MI,
str
oke,
di
abet
es, h
yper
tens
ion,
sel
f ra
ted
heal
th a
t ba
selin
e,
canc
er, c
hron
ic o
bstr
uctiv
e pu
lmon
ary
dise
ase,
inci
dent
hi
p fr
actu
re, b
asel
ine
PA
Wal
king
(kc
al/w
eek)
<
70
1.
00
70-1
86
0.88
(0.
73-1
.06)
18
7-41
9 0.
66 (
0.53
-0.8
2)
420-
897
0.68
(0.
55-0
.84)
>
898
0.
61 (
0.49
-0.7
8)
PA c
hang
e St
ayed
sed
enta
ry
1.00
Be
cam
e ac
tive
0.64
(0.
42-0
.97)
Be
cam
e se
dent
ary
1.07
(0.
81-1
.42)
St
ayed
act
ive
0.
62 (
0.44
-0.8
8)
Haa
pane
n et
al.,
(1
997)
Finl
and
N=
953
35-6
3 ye
ars
of
age
in 1
980
Que
stio
nnai
re:
1980
�
Freq
uenc
y an
d du
ratio
n of
ex
erci
se, s
port
s, p
hysi
cal
recr
eatio
n �
Freq
uenc
y an
d du
ratio
n of
ho
useh
old
chor
es
�Fr
eque
ncy
and
dura
tion
com
mut
ing
wor
k
�To
tal P
A en
ergy
exp
endi
ture
(k
cal/w
eek)
�
Freq
uenc
y of
vig
orou
s PA
(f
requ
ency
/wee
k)
Coro
nary
hea
rt d
isea
se
inci
denc
e an
d m
orta
lity
10 y
ears
Ag
e, s
mok
ing
Tota
l PA
(kca
l/wee
k)
0-90
0
1.00
90
1-15
00
0.73
(0.
38-1
.39)
>
1500
1.25
(0.
72-2
.15)
p
tren
d=0.
178
vPA
(x/w
eek)
>
1x
1.00
>
1x
1.13
(0.
62-2
.07)
p
tren
d=0.
694
144
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Haa
pane
n-N
iem
i, et
al
., (2
000)
Finl
and
N=
1,12
2
35-6
3 ye
ars
of
age
in 1
980
51-7
9 ye
ars
of
age
in 1
996
Que
stio
nnai
re:
1980
�
Wee
kly
freq
uenc
y an
d du
ratio
n in
pas
t ye
ar o
f ex
erci
se, s
port
s, p
hysi
cal
recr
eatio
n,
�W
eekl
y fr
eque
ncy
and
dura
tion
in p
ast
year
of
leis
ure
time
and
hous
ehol
d ch
ores
, �
Wee
kly
freq
uenc
y an
d du
ratio
n in
pas
t ye
ar o
f co
mm
utin
g to
and
fro
m
wor
k �
Glo
bal d
escr
iptio
n of
PA
durin
g pa
st y
ear
�ab
ility
to
wal
k 2k
m
�ab
ility
to
wal
k 2k
m a
nd
clim
b se
vera
l sta
ir fli
ghts
w
ithou
t re
st
�To
tal P
A en
ergy
exp
endi
ture
(k
cal/w
k)
�G
loba
l lei
sure
PA/
wk:
act
ive
(vig
orou
s PA
>1/
wk
and
som
e lig
ht P
A), i
nact
ive
(no
or li
ght
inte
nsity
PA)
�
Abili
ty w
alk
2km
�
Abili
ty w
alk
and
clim
b st
airs
Card
iova
scul
ar d
isea
se
mor
talit
y 16
yea
rs
age,
mar
ital s
tatu
s,
empl
oym
ent
stat
us, p
erce
ived
he
alth
, sm
okin
g st
atus
, al
coho
l con
sum
ptio
n
Tota
l PA
(kca
l/wee
k)
0-80
0
1.00
80
0.1-
1500
0.
43 (
0.16
–1.1
6)
>15
00
1.
17 (
0.51
–2.6
8)
p=0.
046
Glo
bal l
eisu
re P
A vP
A >
1/w
k, li
ght
PA
1.00
no
/ligh
t PA
4.68
(1.
41–1
5.57
) p=
0.00
2 W
alk
2km
abi
lity
No
diff
icul
ty
1.00
So
me
diff
icul
ty
1.25
(0.
53-2
.90)
p=
0.61
4 St
air
clim
bing
abi
lity
No
diff
icul
ty
1.00
So
me
diff
icul
ty
3.38
(1.
22–9
.41)
p=
0.13
145
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
He,
et
al.,
(200
1)
NH
ANES
I
Epid
emio
logi
c Fo
llow
up
Stud
y (U
SA)
N=
809
8 25
-74
year
s of
ag
e in
197
1 an
d 19
75
Mea
n 48
.1 y
ears
Inte
rvie
w:
1971
-5
�Le
isur
e PA
leve
l: lo
w,
med
ium
or
high
(no
val
ues)
Cong
estiv
e he
art
failu
re
(CH
F)
7-21
yea
rs
Aver
age
19 y
ears
ra
ce, C
HD
his
tory
, edu
catio
n,
smok
ing,
alc
ohol
, BP,
hy
pert
ensi
on, c
hole
ster
ol,
over
wei
ght,
dia
bete
s, v
alvu
lar
dise
ase
PA le
vel
Med
ium
/Hig
h 1.
00
Low
1.31
(1.
11–1
.54)
p=
0.0
02
Hu
et a
l.,
(200
0).
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
72,
488
40
-65
year
s of
ag
e in
198
6
Que
stio
nnai
re:
1980
�
Aver
age
hour
s/w
eek
in p
ast
year
in m
oder
ate
and
vigo
rous
PA
(incl
udin
g ga
rden
ing,
bris
k w
alki
ng)
Que
stio
nnai
re:
1980
�
Aver
age
hour
s/w
eek
in p
ast
year
in s
tren
uous
PA
Que
stio
nnai
re:
1986
, 198
8,
1992
�
Aver
age
time/
wee
k sp
ent
wal
king
, jog
ging
, run
ning
, bi
cycl
ing,
cal
isth
enic
s,
aero
bics
, row
ing,
lap
Stro
ke
8 ye
ars
age,
tim
e, s
mok
ing,
BM
I,
men
opau
sal s
tatu
s, p
aren
tal
hist
ory
of M
I, a
lcoh
ol, a
spiri
n,
diab
etes
his
tory
, hyp
erte
nsio
n hi
stor
y, h
ypoc
hole
ster
olem
ia
hist
ory
Tota
l PA
(MET
.hou
r/w
eek)
<
2.0
1.
00
2.1-
4.6
0.
98 (
0.75
-1.2
9)
4.7-
10.4
0.
82 (
0.61
–1.1
0)
10.5
-21.
7 0.
74 (
0.54
–1.0
1)
>21
.7
0.
66 (
0.47
–0.9
1)
p tr
end=
0.00
5
146
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
swim
min
g, r
acqu
et s
port
s �
Usu
al w
alki
ng p
ace
�H
ours
per
wee
k in
str
enuo
us
PA
�To
tal P
A en
ergy
exp
endi
ture
qu
intil
es (
MET
.hou
r/w
eek)
�
Wal
king
ene
rgy
expe
nditu
re
quin
tiles
(M
ET.h
our/
wee
k)
�U
sual
wal
king
pac
e (k
m/h
our)
�
Chan
ge in
PA
betw
een
1980
an
d 19
86 (
For
each
3.5
ho
ur/w
eek
incr
ease
)
Wal
king
(M
ET.h
our/
wee
k)
<0.
5
1.00
0.
6-2.
0
0.76
(0.
56–1
.04)
21
.-3.
8
0.78
(0.
56–1
.07)
3.
9-10
0.70
(0.
52–0
.95)
>
10
0.
66 (
0.48
–0.9
1)
p tr
end=
0.01
W
alki
ng p
ace
(km
/hou
r)
<3.
2
1.
00
3.2-
4.6
0.
81 (
0.63
–1.0
3)
>4.
6
0.49
(0.
36–0
.68)
p
tren
d <
0.0
01
For
each
3.5
hou
r/w
eek
incr
ease
in m
PA a
nd
vPA
0.81
(0.
68-0
.98)
p=
0.03
Kush
i, et
al
., (1
997)
Io
wa
Wom
en's
H
ealth
Stu
dy
(USA
) N
= 4
0,41
7
Que
stio
nnai
re:
1986
�
any
regu
lar
daily
leis
ure
time
PA (
not
occu
patio
nal o
r do
mes
tic)
to k
eep
phys
ical
ly
fit
Card
iova
scul
ar d
isea
se
mor
talit
y 7
year
s
Dai
ly P
A N
o 1.
00
Yes
0.72
(0.
54–0
.95)
147
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
55–6
9 ye
ars
in
1986
�fr
eque
ncy
and
dura
tion
of
mod
erat
e PA
(in
clud
ing
gard
enin
g an
d w
alks
) �
freq
uenc
y an
d du
ratio
n of
vi
goro
us P
A �
Dai
ly P
A �
Mod
erat
e PA
fre
quen
cy
�Vi
goro
us P
A fr
eque
ncy
�PA
leve
l: lo
w (
vPA
<1x
/wee
k or
mPA
<
1x/w
eek)
, med
ium
(vP
A 1x
/wee
k or
mPA
1-
4x/w
eek)
, hig
h (v
PA
>2x
/wee
k or
mPA
>
4x/w
eek)
age,
men
arch
e ag
e,
men
opau
se a
ge, a
ge a
t fir
st
live
birt
h, p
arity
, alc
ohol
, tot
al
ener
gy in
take
, sm
okin
g,
estr
ogen
use
, BM
I at
ba
selin
e, B
MI
at a
ge 1
8,
wai
st t
o hi
p ra
tio, e
duca
tion,
m
arita
l sta
tus
mPA
(fr
eque
ncy)
Ra
rely
/nev
er
1.00
1x
/wk,
few
/mo
0.86
(0.
61–1
.21)
2-
4x/w
eek
0.74
(0.
52–1
.05)
>
4x/w
eek
0.53
(0.
34 –
0.8
2)
p tr
end=
0.00
3 vP
A (f
requ
ency
) Ra
rely
/nev
er
1.00
1/
wk,
few
/mo
0.85
(0.
50–1
.44)
2-
4x/w
eek
0.59
(0.
28–1
.25)
>
4x/w
eek
0.20
(0.
03–1
.41)
p
tren
d=0.
09
PA le
vel (
freq
uenc
y)
Low
1.00
M
ediu
m
0.86
(0.
63–1
.17)
H
igh
0.
55 (
0.38
–0.8
1)
p tr
end=
0.00
2
148
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Lee,
Rex
rode
, Co
ok,
Man
son,
et
al.,
(200
1)
Wom
en's
Hea
lth
Stud
y (U
SA a
nd
Puer
to R
ico)
N
= 3
9,37
2
>45
yea
rs o
f ag
e
Que
stio
nnai
re:
1992
-5
�av
erag
e tim
e pe
r w
eek
spen
t in
the
pas
t ye
ar:
wal
king
/hik
ing,
jogg
ing,
ru
nnin
g, b
icyc
ling,
aer
obic
ex
erci
ses,
low
-inte
nsity
ex
erci
se, r
acqu
et s
port
s, la
p sw
imm
ing
�us
ual w
alki
ng p
ace
�nu
mbe
r of
flig
hts
of s
tairs
cl
imbe
d da
ily
�To
tal P
A en
ergy
exp
endi
ture
(k
cal/w
k)
�Vi
goro
us P
A en
ergy
ex
pend
iture
(kc
al/w
k)
�W
alki
ng (
ime/
wk)
exc
lude
s vP
A)
�W
alki
ng p
ace
(km
/hou
r)
Coro
nary
hea
rt d
isea
se
4-7
year
s Av
erag
e 5
yrs
stud
y co
nditi
on, s
mok
ing
stat
us, a
lcoh
ol c
onsu
mpt
ion,
sa
tura
ted
fat
inta
ke, f
ibre
in
take
, fru
it an
d ve
geta
ble
cons
umpt
ion,
men
opau
sal
stat
us, h
orm
one
use,
par
enta
l M
I hi
stor
y, B
MI,
hy
pert
ensi
on, e
leva
ted
chol
este
rol,
diab
etes
Tota
l PA
(kca
l/wk)
<
200
1.
00
200-
599
0.79
(0.
56–1
.12)
60
0-14
99
0.55
(0.
37–0
.82)
>
1500
0.75
(0.
50–1
.12)
p
tren
d=0.
03
vPA
(kca
l/wk)
0
& <
200
othe
r PA
1.
00
0 &
>20
0 ot
her
PA
0.65
(0.
46–0
.91)
1-
199
vPA
1.
18 (
0.79
–1.7
8)
200-
499
vPA
0.
96 (
0.60
–1.5
5)
>50
0 vP
A
0.63
(0.
38–1
.04)
p
tren
d=0.
45
Wal
king
(tim
e/w
k)
No
wal
king
1.
00
1-59
min
s 0.
86 (
0.52
–1.2
9)
1.0-
1.5
hrs
0.49
(0.
28–0
.86)
>
2hrs
0.48
(0.
29–0
.78)
p
tren
d=0.
001
149
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Wal
king
pac
e (k
m/h
our)
N
o w
alki
ng
1.00
<
3.2
0.
56 (
0.32
–0.9
7)
3.2-
4.7
0.
71 (
0.47
–1.0
5)
>4.
8
0.52
(0.
30–0
.90)
p
tren
d=0.
02
Man
son,
et
al.,
(200
2)
Wom
en's
Hea
lth
Initi
ativ
e O
bser
vatio
nal
Stud
y (U
SA)
N=
73,
743
50-7
9 ye
ars
of
age
betw
een
1994
and
199
8
Que
stio
nnai
re:
1994
-98
�fr
eque
ncy
of s
tren
uous
, m
oder
ate,
mild
PA
�fr
eque
ncy
and
dura
tion
of
wal
king
�us
ual w
alki
ng p
ace
�
Tota
l PA
ener
gy e
xpen
ditu
re
quin
tiles
(M
ET.h
ours
/wee
k)
�W
alki
ng e
nerg
y ex
pend
iture
qu
intil
es (
MET
.hou
rs/w
eek)
�
Vigo
rous
PA
time
(vPA
) qu
intil
es (
min
s/w
eek)
�
Wal
king
pac
e (m
iles/
hour
)
Card
iova
scul
ar d
isea
se
5.9
year
s (m
ean
3.2y
rs)
age,
sm
okin
g, B
MI,
wai
st/h
ip
ratio
, alc
ohol
, age
at
men
opau
se, H
RT,
par
enta
l hi
stor
y M
I, e
thni
city
, ed
ucat
ion,
fam
ily in
com
e,
diet
ary
varia
bles
Tota
l PA
(MET
.hou
rs/w
eek)
0-
2.4
1.
00
2.5-
7.2
0.
89 (
0.75
–1.0
4)
7.3-
13.4
0.
81 (
0.68
-0.9
7)
13.5
-23.
3 0.
78 (
0.66
–0.9
3)
>23
.4
0.
72 (
0.59
–0.8
7)
p tr
end
<0.
001
Wal
king
(M
ET.h
ours
/wee
k)
0
1.00
0.
1-2.
5
0.91
(0.
78–1
.07)
2.
6-5.
0
0.82
(0.
69–0
.97)
5.
1-10
.0
0.75
(0.
63–0
.89)
>
10.0
0.68
(0.
56–0
.82)
p
tren
d <
0.00
1
150
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
vPA
(min
s/w
eek)
0
1.
00
1-60
0.91
(0.
73–1
.12)
61
-100
0.
81 (
0.63
–1.0
6)
101-
150
0.85
(0.
64–1
.13)
>
150
0.
76 (
0.58
–1.0
0)
p tr
end=
0.01
Co
rona
ry H
eart
Dis
ease
5.
9 ye
ars
(mea
n 3.
2yrs
) ag
e, s
mok
ing,
BM
I, w
aist
/hip
ra
tio, a
lcoh
ol, a
ge a
t m
enop
ause
, HRT,
par
enta
l hi
stor
y M
I, e
thni
city
, ed
ucat
ion,
fam
ily in
com
e,
diet
ary
varia
bles
Tota
l PA
(MET
.hou
rs/w
eek)
0-
2.4
1.
00
2.5-
7.2
0.
73 (
0.53
–0.9
9)
7.3-
13.4
0.
69 (
0.51
–0.9
5)
13.5
-23.
3 0.
68 (
0.50
–0.9
3)
>23
.4
0.
47 (
0.33
–0.6
7)
p tr
end
<0.
001
Wal
king
(M
ET.h
ours
/wee
k)
0
1.00
0.
1-2.
5
0.71
(0.
53–0
.96)
2.
6-5.
0
0.60
(0.
44–0
.83)
5.
1-10
.0
0.54
(0.
39–0
.76)
>
10.0
0.61
(0.
44–0
.84)
p
tren
d=0.
004
151
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
vPA
(min
s/w
eek)
0
1.
00
1-60
1.12
(0.
79-1
.60)
61
-100
0.
56 (
0.32
-0.9
8)
101-
150
0.73
(0.
43-1
.25)
>
150
0.
58 (
0.34
-0.9
9)
p tr
end=
0.00
8
Man
son,
et
al.,
(199
9)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
72,
488
40
-65
year
s of
ag
e in
198
6
Que
stio
nnai
re:
1986
�
aver
age
time
per
wee
k in
pa
st y
ear:
wal
king
/hik
ing,
jo
ggin
g, r
unni
ng, b
icyc
ling,
ae
robi
c ex
erci
ses,
low
-in
tens
ity e
xerc
ise,
rac
quet
sp
orts
, lap
sw
imm
ing
�us
ual w
alki
ng p
ace
�nu
mbe
r of
flig
hts
of s
tairs
cl
imbe
d da
ily
�av
erag
e nu
mbe
r of
hou
rs in
m
oder
ate
or v
igor
ous
PA
(incl
udin
g ga
rden
ing
and
wal
king
) in
pre
viou
s ye
ar
Coro
nary
eve
nts
(non
fat
al M
I or
dea
th f
rom
cor
onar
y di
seas
e)
8 ye
ars
ag
e, s
tudy
per
iod,
sm
okin
g,
alco
hol,
BMI,
men
opau
sal
stat
us, H
RT, a
spiri
n,
mul
tivita
min
, vita
min
E,
pare
ntal
his
tory
of
MI,
di
abet
es h
isto
ry h
yper
tens
ion,
hy
poch
oles
tero
lem
ia.
Tota
l PA
(MET
.hou
rs/w
k)
<2.
0
1.00
2.
1-4.
6
0.88
(0.
71–1
.10)
4.
7-10
.4
0.81
(0.
64–1
.02)
10
.5-2
1.7
0.74
(0.
58–0
.95)
>
21.7
0.66
(0.
51–0
.86)
p
tren
d=0.
002
Wal
king
(ex
clud
ing
vPA)
(M
ET.h
ours
/wk)
<
0.5
1.
00
0.6-
2.0
0.
78 (
0.57
–1.0
6)
2.1-
3.8
0.
88 (
0.65
-1.2
1)
3.9-
10
0.
70 (
0.51
–0.9
5)
>10
.0
0.
65 (
0.47
–0.9
1)
p tr
end=
0.02
152
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�To
tal P
A en
ergy
exp
endi
ture
qu
intil
es (
MET
.hou
rs/w
k)
�W
alki
ng e
nerg
y ex
pend
iture
qu
intil
es (
MET
.hou
rs/w
k)
�U
sual
wal
king
pac
e (k
m/h
our)
�
Wal
king
(W
) &
vPA
(V)
(M
ET.h
ours
/wk)
Wal
king
pac
e (k
m/h
our)
<
3.2
1.
00
3.2-
4.6
0.
75 (
0.59
–0.9
6)
>4.
6
0.64
(0.
47–
0.88
)
Wal
king
(W
) &
vPA
(V)
(M
ET.h
ours
/wk)
W
(0-0
.6)
& V
(0)
1.
00
W(0
-0.6
) &
V(0
.1-6
.9)
0.78
(0.
55-1
.09)
W
(0-0
.6)
& V
(>7)
0.76
(0.
49-1
.17)
W
(0.7
-6.9
) &
V(0
)
0.84
(0.
67-1
.06)
W
(0.7
-6.9
) &
V(0
.1-6
.9) 0
.86
(0.6
5-1.
13)
W(0
.7-6
.9)
& V
(>7)
0.59
(0.
42-0
.82)
W
(>7)
& V
(0)
0.
74 (
0.57
-0.9
7)
W(>
7) &
V(0
.1-6
.9)
0.
56 (
0.36
-0.8
8)
W(>
7) &
V(>
7)
0.70
(0.
51-0
.95)
Nak
ayam
a e
t al
., (1
997)
(Jap
an)
N=
1,3
41
>40
yea
rs o
f ag
e 40
-49
(n=
417)
50
-99
(n=
398)
60
–69
(n=
309)
>
70 (
n=21
7)
Que
stio
nnai
re:
1977
�
Tota
l PA
ener
gy
expe
nditu
re:
heav
y,
mod
erat
e, li
ght
(c
ateg
orie
s st
ated
as
cons
iste
nt
with
nat
iona
l gui
delin
es)
Stro
ke
15.5
yea
rs
age,
BP,
BM
I, E
CG, s
mok
ing
amou
nt, a
lcoh
ol, h
isto
ry I
HD
, CV
D h
ealth
Tota
l PA
M
oder
ate
1.00
Li
ght
1.
95 (
1.03
–3.6
8)
153
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Paga
nini
-Hill
&
Bar
reto
(2
001)
Leis
ure
Wor
ld
Coho
rt S
tudy
(U
SA)
N=
853
2 44
-101
yea
rs o
f ag
e M
edia
n=74
yea
rs
of a
ge
Que
stio
nnai
re:
1981
or
1983
or
1985
Ex
erci
se (
hour
s/da
y)
Stro
ke
13–1
7 ye
ars
Exer
cise
(ho
urs/
day)
<
0.5
1.
00
1
0.88
>
1.0
0.
83
p tr
end
<0.
05
(no
conf
iden
ce in
terv
als
prov
ided
)
Rock
hill,
et
al
., (2
001)
N
urse
s H
ealth
St
udy
(USA
) N
= 8
0,34
8 30
-55
year
s of
ag
e in
197
6
Que
stio
nnai
re
�19
80:
aver
age
hour
s pe
r w
eek
in P
A (in
clud
ed
gard
enin
g, w
alki
ng,
hous
ewor
k) d
urin
g la
st y
ear
�19
82:
aver
age
hour
s pe
r w
eek
in s
tren
uous
PA
�19
86, 1
988,
199
2: a
vera
ge
hour
s pe
r w
eek
in p
revi
ous
year
doi
ng w
alki
ng/h
ikin
g,
jogg
ing,
run
ning
, bic
yclin
g,
swim
min
g, r
acke
t sp
orts
, ae
robi
cs
�us
ual w
alki
ng p
ace
�To
tal P
A (h
ours
/wee
k)
Card
iova
scul
ar d
isea
se
mor
talit
y 14
yea
rs
age,
sm
okin
g, a
lcoh
ol, h
eigh
t,
BMI,
pos
t m
enop
ausa
l ho
rmon
e us
e
Tota
l PA
(hou
rs/w
eek)
<
1 1.
00
1-1.
9 0.
80 (
0.68
–0.9
6)
2-3.
9 0.
74 (
0.62
–0.8
8)
4-6.
9 0.
62 (
0.50
–0.7
7)
>7
0.69
(0.
49–0
.97)
p
tren
d=<
0.0
01
154
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Sess
o, e
t al
., (1
999)
Penn
sylv
ania
Al
umni
Stu
dy
(USA
) N
= 1
,564
M
ean
age
45.5
ye
ars
Que
stio
nnai
re:
1962
�
daily
num
ber
of f
light
s of
st
airs
clim
bed,
blo
cks
wal
ked
and
spor
ts p
laye
d �
Tota
l PA
ener
gy e
xpen
ditu
re
(kca
l/wk)
�
Flig
hts
of s
tairs
clim
bed
(num
ber/
day)
�
Bloc
ks w
alke
d (n
umbe
r/da
y)
�Sp
orts
ene
rgy
expe
nditu
re
(kca
l/wk)
Card
iova
scul
ar d
isea
se
31 y
ears
ag
e, B
MI,
hyp
erte
nsio
n,
diab
etes
, sm
okin
g, f
amily
hi
stor
y CH
D
Tota
l PA
(kca
l/wk)
, all
wom
en
<50
0
1.00
50
0-99
9 0.
99 (
0.69
–1.4
1)
>10
00
0.
88 (
0.62
–1.2
5)
p tr
end=
0.45
To
tal P
A (k
cal/w
k), A
ge <
45 y
ears
, <
500
1.
00
500-
999
1.57
(0.
79–3
.10)
>
1000
0.94
(0.
47–1
.86)
p
tren
d=0.
57
Tota
l PA
(kca
l/wk)
, Age
>45
yea
rs,
<50
0
1.00
50
0-99
9 0.
83 (
0.54
–1.2
7)
>10
00
0.
88 (
0.58
–1.3
3)
p tr
end=
0.62
St
airs
clim
bed
(num
ber/
day)
<
4 1.
00
4-11
0.
86 (
0.60
–1.2
3)
>12
1.
01 (
0.69
–1.4
7)
p tr
end=
0.89
155
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Bloc
ks w
alke
d (n
umbe
r/da
y)
<4
1.00
4-
9 0.
84 (
0.59
–1.1
9)
>10
0.
67 (
0.45
–1.0
1)
p tr
end=
0.05
4 Sp
orts
(kc
al/w
k)
0 1.
00
1-99
9 1.
23 (
0.74
–2.0
3)
>10
00
1.32
(0.
74–2
.37)
p
tren
d=0.
33
Wel
ler
&
Core
y (1
998)
Cana
da F
itnes
s Su
rvey
(Ca
nada
) N
= 6
,620
>
30 y
ears
of
age
in 1
981
Que
stio
nnai
re:
198
0 �
Type
, fre
quen
cy, d
urat
ion,
in
tens
ity o
f PA
dur
ing
prev
ious
yea
r (in
clud
es
hous
ehol
d ch
ores
) �
Tota
l PA
ener
gy e
xpen
ditu
re
quar
tiles
(kc
al/k
g/da
y)
�Le
isur
e PA
ene
rgy
expe
nditu
re q
uart
iles
(kca
l/kg/
day)
Card
iova
scul
ar m
orta
lity
7 ye
ars
age
(adj
ustm
ent
for
mar
ital
stat
us, e
duca
tion,
inco
me,
se
lf re
port
ed h
ealth
, tob
acco
us
e di
d no
t al
ter
resu
lts)
Tota
l PA
(kca
l/kg/
day)
0-
3.9
1.
00
>3.
9-7.
0 1.
01 (
0.68
–1.5
1)
>7.
0-11
.3
0.70
(0.
44–1
.11)
>
11.3
0.51
(0.
28–0
.91)
Le
isur
e PA
(kc
al/k
g/da
y)
0-0.
1
1.00
>
0.1-
0.5
0.79
(0.
46–1
.37)
>
0.5-
1.6
1.08
(0.
72–1
.64)
>
1.6
0.
80 (
0.50
–1.2
6)
156
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�N
on-le
isur
e en
ergy
ex
pend
iture
(ho
useh
old
chor
es)
quar
tiles
(k
cal/k
g/da
y)
�Le
isur
e PA
leve
l: se
dent
ary
(<3
hour
s/w
eek
for
<9
mon
ths)
, mod
erat
e (>
3 ho
urs/
wee
k <
9 m
onth
s or
<
3 ho
urs/
wee
k fo
r >
9 m
onth
s), h
igh
(>3
hour
s/w
eek
for
>9
mon
ths)
Non
leis
ure
PA (
kcal
/kg/
day)
0-
0.28
1.00
>
2.8-
5.9
0.85
(0.
56–1
.28)
>
5.9-
9.8
0.61
(0.
39–0
.96)
>
9.8
0.
49 (
0.28
–0.8
6)
Leis
ure
PA le
vel
Sede
ntar
y 1.
00
Mod
erat
e 0.
90 (
0.56
–1.4
5)
Hig
h
0.78
(0.
52–1
.15)
N
otes
. BP
: bl
ood
pres
sure
, CVD
: ca
rdio
vasc
ular
dis
ease
, CH
D:
cor
onar
y he
art
dise
ase,
CH
F: c
oron
ary
hear
t fa
ilure
, ECG
: el
ectr
ocar
diog
ram
, HD
L-C:
H
DL
chol
este
rol,
HRT
: ho
rmon
e re
plac
emen
t th
erap
y, I
HD
: is
cahe
mic
hea
rt d
isea
se, k
cal:
kilo
calo
ries,
kg:
kilo
gram
, km
: ki
lom
eter
s, m
: m
iles,
MET
: m
etab
olic
equ
ival
ent,
MI:
myo
card
ial i
nfar
ctio
n, m
PA:
mod
erat
e in
tens
ity p
hysi
cal a
ctiv
ity, P
A: p
hysi
cal a
ctiv
ity, S
BP:
syst
olic
blo
od p
ress
ure,
T-C
: to
tal
chol
este
rol,
vPA:
vig
orou
s PA
.
157
AP
PEN
DIX
B
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Dia
bete
s.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Dot
eval
l et
al.,
(200
4)
Got
ebor
g BE
DA
Stud
y of
CVD
(S
wed
en)
N=
1,3
51
39-6
5 ye
ars
of a
ge
Que
stio
nnai
re:
197
9-81
�
PA a
t w
ork
and
leis
ure
(incl
udin
g w
alki
ng, g
arde
ning
) �
PA le
vel:
sede
ntar
y, n
ot
sede
ntar
y (m
PA <
4 h
rs/w
k O
R re
gula
r, s
tren
uous
or
very
st
renu
ous
PA)
16-1
9 ye
ars
age,
sm
okin
g, m
enop
ause
, BM
I, S
BP, c
hole
ster
ol,
trig
lyce
rides
PA le
vel
Not
sed
enta
ry
1.00
Se
dent
ary
1.56
(0.
96-2
.53)
p
tren
d=0.
071
Fols
om e
t al
., (2
000)
Io
wa
Wom
en's
H
ealth
Stu
dy
(USA
) N
= 3
4,25
7 55
-69
year
s of
age
Que
stio
nnai
re:
1986
�
Dai
ly P
A (n
ot d
one
at h
ome
or
at w
ork)
to
keep
fit
�Fr
eque
ncy
in m
oder
ate
PA
(incl
udin
g ga
rden
ing,
wal
king
) or
vig
orou
s PA
�
Part
icip
atio
n in
reg
ular
leis
ure
PA (
unde
fined
) �
Mod
erat
e PA
fre
quen
cy
�Vi
goro
us P
A fr
eque
ncy
12 y
ears
ag
e, e
duca
tion,
sm
okin
g,
alco
hol,
estr
ogen
, die
t,
fam
ily h
isto
ry o
f di
abet
es,
BMI,
wai
st-h
ip r
atio
Reg
ular
PA
No
1.00
Ye
s 0.
86 (
0.78
-0.9
5)
mPA
(fr
eque
ncy)
ra
rely
/nev
er
1.00
1x
/wk,
few
/mo
0.90
(0.
79-1
.01)
2-
4 x/
wk
0.86
(0.
76-0
.98)
>
4 x/
wk
0.73
(0.
62-0
.85)
p
tren
d <
0.00
1
158
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
�PA
inde
x: lo
w (
vPA
or m
PA
rare
ly o
r a
few
x/m
onth
),
med
ium
(vP
A 1
x/w
eek
OR
mPA
1-4
x/w
eek)
, hig
h (v
PA
>2
x/w
eek
OR
mPA
>4
x/w
eek)
vPA
(fre
quen
cy)
rare
ly/n
ever
1.
00
1x/w
k, f
ew/m
o 0.
92 (
0.76
-1.1
0)
2-4
x/w
k 0.
88 (
0.70
-1.1
1)
>4x
/wk
0.
64 (
0.41
–1.0
1)
p tr
end
<0.
05
PA in
dex,
all
wom
en
Low
1.00
M
ediu
m 0
.91
(0.8
2-1.
02)
Hig
h
0.79
(0.
70-0
.90)
p
tren
d <
0.00
1 PA
inde
x, a
ge 5
5-59
yea
rs
Low
1.00
M
ediu
m 0
.76
(0.6
2-0.
92)
Hig
h
0.62
(0.
50-0
.78)
p
tren
d <
0.00
1 PA
inde
x, a
ge 6
0-64
yea
rs
Low
1.00
M
ediu
m
0.73
(0.
60-0
.88)
H
igh
0.
58 (
0.47
-0.7
1)
p tr
end
<0.
001
159
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
PA in
dex,
age
65-
69 y
ears
, Lo
w
1.
00
Med
ium
0.
76 (
0.62
-0.9
3)
Hig
h
0.54
(0.
43-0
.68)
p
tren
d <
0.0
01
Haa
pane
n,
et a
l.,
(199
7)
Cens
us
(Fin
land
) N
= 1
,500
35
-63
year
s of
age
in
198
0
Que
stio
nnai
re:
1980
�
Freq
uenc
y an
d du
ratio
n of
ex
erci
se, s
port
s, p
hysi
cal
recr
eatio
n
�le
isur
e tim
e an
d ho
useh
old
chor
es
�co
mm
utin
g to
and
fro
m w
ork
�
PA e
nerg
y ex
pend
iture
(k
cal/w
eek)
�
Vigo
rous
PA
(fre
quen
cy/w
k)
10 y
ears
age
Tota
l PA
(kca
l/wk)
0-
900
1.
00
901-
1500
1.
17 (
0.50
-2.7
0)
>15
00
2.
64 (
1.28
-5.4
4)
p tr
end=
0.00
6 vP
A (f
requ
ency
/wk)
>
1 1.
00
<1
2.23
(0.
90-5
.23)
p
tren
d=0.
043
160
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Hsi
a et
al.,
(2
005)
W
omen
's H
ealth
In
itiat
ive
Obs
erva
tiona
l St
udy
(USA
) N
= 8
6,70
8 Ca
ucas
ian
n=
74,
240,
av
erag
e ag
e 64
ye
ars
Af
rican
Am
eric
an
n=6,
465
aver
age
age
62 y
ears
H
ispa
nic
n= 3
,231
av
erag
e ag
e 60
ye
ars
Asia
n/Pa
cific
Is
land
er
n=2,
445
aver
age
age
64
year
s
Que
stio
nnai
re:
199
4-98
�
freq
uenc
y an
d du
ratio
n of
fou
r w
alki
ng s
peed
s, s
tren
uous
ex
erci
se, m
oder
ate
exer
cise
, lig
ht e
xerc
ise
�
Tota
l PA
ener
gy e
xpen
ditu
re
(MET
S.ho
urs/
wk)
�
Wal
king
ene
rgy
expe
nditu
re
(MET
S.ho
urs/
wk)
4-8
year
s Av
erag
e 5.
1 ye
ars
age,
BM
I, a
lcoh
ol u
se,
educ
atio
n, s
mok
ing,
hy
pert
ensi
on,
hype
rcho
lest
erol
emia
, di
etar
y fib
re, c
arbo
hydr
ate
ener
gy
Wal
king
(M
ETS.
hour
s/w
k), C
ombi
ned
grou
ps
0
1.00
0.
5-2.
5
0.77
(0.
68-0
.87)
2.
6-5.
0
0.87
(0.
77-0
.99)
5.
1-10
.0
0.74
(0.
64-0
.85)
10
.1-4
0.8
0.82
(0.
70-0
.95)
p
tren
d=0.
009
Wal
king
(M
ETS.
hour
s/w
k), C
auca
sian
0
1.
00
0.5-
2.5
0.
85 (
0.74
-0.9
8)
2.6-
5.0
0.
87 (
0.75
-1.0
1)
5.1-
10.0
0.
75 (
0.64
-0.8
9)
10.1
-40.
8 0.
74 (
0.62
-0.8
9)
p tr
end
< 0
.001
W
alki
ng (
MET
S.ho
urs/
wk)
, Afr
ican
Am
eric
an
0
1.00
0.
5-2.
5
0.58
(0.
38-0
.87)
2.
6-5.
0
0.92
(0.
68-1
.24)
5.
1-10
.0
0.78
(0.
54-1
.12)
10
.1-4
0.8
0.84
(0.
59-1
.21)
p
tren
d=0.
478
161
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Amer
ican
Ind
ian
n= 3
27
aver
age
age
62
year
s
Wal
king
(M
ETS.
hour
s/w
k), H
ispa
nic
0
1.00
0.
5-2.
5
0.87
(0.
50-1
.53)
2.
6-5.
0
0.59
(0.
32-1
.08)
5.
1-10
.0
0.66
(0.
37-1
.18)
10
.1-4
0.8
0.91
(0.
51-1
.62)
p
tren
d=0.
644
Wal
king
(M
ETS.
hour
s/w
k), A
sian
/Pac
ific
Isla
nder
0
1.
00
0.5-
2.5
0.
66 (
0.30
-1.4
4)
2.6-
5.0
1.
02 (
0.51
-2.0
5)
5.1-
10.0
0.
87 (
0.41
-1.8
5)
10.1
-40.
8 1.
53 (
0.79
-2.9
7)
p tr
end=
0.11
5 To
tal P
A (M
ETS.
hour
s/w
k), C
ombi
ned
0-2.
3
1.00
2.
3-7.
4
0.91
(0.
80-1
.03)
7.
5-13
.9
0.80
(0.
70-1
.91)
14
.0-2
3.4
0.86
(0.
75-0
.99)
23
.5-1
43.0
0.
78 (
0.67
-0.9
1)
p tr
end=
0.00
2
162
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Tota
l PA
(MET
S.ho
urs/
wk)
, Cau
casi
an
0-2.
3
1.00
2.
3-7.
4
0.88
(0.
76-1
.01)
7.
5-13
.9
0.74
(0.
64-0
.87)
14
.0-2
3.4
0.80
(0.
68-0
.94)
23
.5-1
43.0
0.
67 (
0.56
-0.8
1)
p tr
end=
0.00
2 To
tal P
A (M
ETS.
hour
s/w
k), A
fric
an A
mer
ican
0-
2.3
1.
00
2.3-
7.4
0.
90 (
0.64
-1.2
6)
7.5-
13.9
0.
84 (
0.61
-1.1
8)
14.0
-23.
4 0.
77 (
0.54
-1.1
0)
23.5
-143
.0
0.95
(0.
66-1
.37)
p
tren
d=0.
150
Tota
l PA
(MET
S.ho
urs/
wee
k), H
ispa
nic
0-2.
3
1.00
2.
3-7.
4
0.87
(0.
50-1
.51)
7.
5-13
.9
0.67
(0.
38-1
.20)
14
.0-2
3.4
0.96
(0.
54-1
.70)
23
.5-1
43.0
0.
70 (
0.36
-1.3
7)
p tr
end=
0.72
1
163
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Tota
l PA
(MET
S.ho
urs/
wee
k), A
sian
/Pac
ific
Isl
0-2.
3
1.00
2.
3-7.
4
1.00
(0.
49-2
.07)
7.
5-13
.9
0.99
(0.
46-2
.13)
14
.0-2
3.4
1.06
(0.
50-2
.27)
23
.4-1
43.0
1.
37 (
0.62
-3.0
2)
p tr
end=
0.98
6
Hu,
et
al.,
(2
003)
N
urse
s' H
ealth
St
udy
(USA
) N
= 6
8,49
7 40
-65
year
s of
age
Que
stio
nnai
re:
1992
�
aver
age
wee
kly
time
sitt
ing
whi
le w
atch
ing
TV, a
t w
ork,
at
hom
e, a
way
from
hom
e,
driv
ing
�tim
e sp
ent
stan
ding
or
wal
king
ar
ound
at
hom
e, a
t w
ork
Que
stio
nnai
re:
1992
, 199
4, 1
996
�
aver
age
time/
wee
k w
alki
ng,
jogg
ing,
run
ning
, cyc
ling,
ae
robi
cs, l
ap s
wim
min
g, r
acke
t sp
orts
�
Usu
al w
alki
ng p
ace
�Si
ttin
g w
atch
ing
tele
visi
on
(hou
rs/w
eek)
�
Sitt
ing
at w
ork,
aw
ay fro
m
hom
e, d
rivin
g (h
ours
/wee
k)
6 ye
ars
age,
sm
okin
g, a
lcoh
ol,
BMI,
men
opau
sal s
tatu
s,
HRT,
asp
irin,
par
enta
l hi
stor
y of
MI,
fam
ily
hist
ory
of d
iabe
tes,
PA,
gl
ycem
ic lo
ad,
poly
unsa
tura
ted
fatt
y ac
id,
cere
al f
ibre
, tra
ns f
at
Sitt
ing
wat
chin
g te
levi
sion
(hr
s/w
k)
0-1
1.00
2-
5 1.
09 (
0.85
-1.3
9)
6-20
1.
30 (
1.03
-1.6
3)
21-4
0 1.
44 (
1.12
-1.8
5)
>40
1.
70 (
1.20
-2.4
3)
p tr
end
< 0
.001
Si
ttin
g at
wor
k, a
way
fro
m h
ome,
driv
ing
(hrs
/wk)
0-
1 1.
00
2-5
0.99
(0.
81-1
.20)
6-
20
1.10
(0.
91-1
.33)
21
-40
1.12
(0.
89-1
.41)
>
40
1.48
(1.
10-2
.01)
p
tren
d=0.
005
164
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
�Si
ttin
g at
hom
e (n
ot T
V)
(hou
rs/w
eek)
�
Stan
ding
or
wal
king
aro
und
hom
e (h
ours
/wee
k)
�St
andi
ng/w
alki
ng a
roun
d at
w
ork
(hou
rs/w
eek)
�
Com
bine
d PA
and
TV
cate
gorie
s: m
ost
activ
e (h
ighe
st t
ertil
e fo
r PA
MET
+
TV <
6 hr
s/w
k);
mos
t se
dent
ary
(>20
hrs
/wk
TV +
leas
t M
ETS.
hr/w
eek)
Oth
er s
ittin
g at
hom
e i.e
., no
t TV
(h
rs/w
k)
0-1
1.00
2-
5 0.
87 (
0.67
-1.1
3)
6-20
0.
98 (
0.76
-1.2
6)
21-4
0 0.
94 (
0.70
-1.2
4)
>40
1.
54 (
1.10
-2.1
8)
p tr
end=
0.00
4 St
andi
ng/w
alki
ng a
roun
d ho
me
(hrs
/wk)
0-
1 1.
00
2-5
1.13
(0.
80-1
.59)
6-
20
1.03
(0.
74-1
.44)
21
-40
0.88
(0.
63-1
.24)
>
40
0.83
(0.
58-1
.19)
p
tren
d <
0.0
01
Stan
ding
/wal
king
aro
und
at w
ork
(hrs
/wk)
0-
1 1.
00
2-5
0.92
(0.
76-1
.12)
6-
20
0.93
(0.
78-1
.12)
21
-40
0.93
(0.
76-1
.13)
>
40
0.94
(0.
74-1
.18)
p
tren
d=0.
86
165
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Com
bine
d PA
and
TV
cate
gorie
s m
ost
activ
e 1.
00
mos
t se
dent
ary
2.89
(2.
21-3
.79)
Hu,
et
al.,
(199
9)
Nur
ses'
Hea
lth
Stud
y (U
SA)
N=
70,
102
40-6
5 ye
ars
of a
ge
Que
stio
nnai
re:
1986
, 198
8, 1
992
�av
erag
e tim
e/w
eek
in w
alki
ng,
jogg
ing,
run
ning
, cyc
ling,
ae
robi
cs, l
ap s
wim
min
g, r
acke
t sp
orts
�
usua
l wal
king
pac
e �
Cum
ulat
ive
aver
age
(198
6-92
) To
tal P
A en
ergy
exp
endi
ture
qu
intil
es (
MET
.hou
r/w
eek)
�
Wal
king
ene
rgy
expe
nditu
re
quin
tiles
(M
ET.h
our/
wee
k)
�U
sual
wal
king
pac
e (k
ilom
eter
s/ho
ur):
eas
y (<
3.2
km/h
r), n
orm
al (
3.2-
4.8)
, bris
k or
ver
y br
isk
(>4.
8)
8 ye
ars
age,
sm
okin
g, a
lcoh
ol,
BMI,
men
opau
sal s
tatu
s,
HRT,
asp
irin,
par
enta
l hi
stor
y of
MI,
his
tory
of
diab
etes
, hyp
erte
nsio
n,
hypo
chol
este
role
mia
Tota
l PA
(MET
.hrs
/wk)
0-
0.2
1.
00
2.1-
4.6
0.
84 (
0.72
-0.9
7)
4.7-
10.4
0.
87 (
0.75
-1.0
2)
10.5
-21.
7 0.
77 (
0.65
-0.9
1)
>21
.7
0.
74 (
0.62
-0.8
9)
p tr
end=
0.00
2 W
alki
ng (
MET
.hrs
/wk)
<
0.5
1.
00
0.6-
2.0
0.
95 (
0.79
-1.1
5)
2.1-
3.8
0.
80 (
0.65
-0.9
9)
3.9-
9.9
0.
81 (
0.66
-1.0
1)
>10
0.74
(0.
59-0
.93)
p
tren
d=0.
01
Wal
king
pac
e Ea
sy
1.
00
Nor
mal
0.
86 (
0.73
-1.0
1)
Bris
k/v.
bris
k 0.
59 (
0.47
-0.7
3)
p tr
end=
0.01
166
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Kris
ka, e
t al
., (2
003)
Pi
ma
Indi
ans
(USA
) N
= 1
,052
15
-59
year
s of
age
Inte
rvie
w:
1987
-200
0 �
PA d
urin
g pa
st y
ear
�Fr
eque
ncy
and
dura
tion
of
part
icip
atio
n in
spe
cifie
d ty
pes
of le
isur
e PA
�
Tim
e sp
ent
wal
king
/cyc
ling
to
wor
k �
Hou
rs s
pent
sitt
ing
at w
ork
�Ph
ysic
al a
ctiv
ities
don
e at
wor
k �
Leis
ure
PA e
nerg
y ex
pend
iture
(M
ET.h
ours
/wee
k)
�To
tal P
A en
ergy
exp
endi
ture
(M
ET.h
ours
.wee
k)
13 y
ears
(a
vera
ge 6
yea
rs)
age,
BM
I
Leis
ure
PA (
MET
.hou
rs/w
eek)
<
16
1.00
>
16
0.74
(0.
56-0
.97)
p=
0.03
To
tal P
A (M
ET.h
ours
/wee
k)
<16
1.
00
>16
0.
78 (
0.60
-1.0
2)
p=0.
07
Wei
nste
in,
et a
l.,
(200
4)
Wom
en's
Hea
lth
Stud
y (U
SA)
37,8
78
>45
yea
rs in
199
2
Que
stio
nnai
re:
1992
�
Aver
age
time
in p
ast
year
sp
ent
on w
alki
ng/h
ikin
g,
jogg
ing,
run
ning
, bic
yclin
g,
aero
bics
, lap
sw
imm
ing,
ten
nis,
ra
cket
spo
rts,
low
inte
nsity
ex
erci
se e
.g.,
yoga
�
Num
ber
of f
light
s of
sta
irs
clim
bed
daily
Aver
age
6.6
year
s ag
e, f
amily
his
tory
di
abet
es, a
lcoh
ol u
se,
smok
ing
stat
us, h
orm
one
ther
apy,
hyp
erte
nsio
n,
high
cho
lest
erol
, die
tary
fa
ctor
s, B
MI,
stu
dy g
roup
Mee
ting
PA g
uide
lines
(kc
al/w
eek)
<
1000
1.00
>
1000
0.91
(0.
80-1
.03)
To
tal P
A (k
cal/w
k)
<20
0
1.00
20
0-59
9 0.
91 (
0.79
-1.0
6)
600-
1499
0.
86 (
0.74
-1.0
1)
>15
00
0.
82 (
0.70
-0.9
7)
p tr
end=
0.01
167
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
�M
eetin
g PA
gui
delin
es
(kca
l/wk)
�
Tota
l PA
ener
gy e
xpen
ditu
re
quar
tiles
(kc
al/w
eek)
�
Wal
king
tim
e (h
ours
/wee
k)
Wal
king
tim
e (h
rs/w
k)
No
wal
king
1.
00
<1
0.
95 (
0.82
-1.1
0)
1.0-
1.5
0.
87 (
0.73
-1.0
2)
2.0-
3.0
0.
66 (
0.54
-0.8
1)
>4
0.
89 (
0.73
-1.0
9)
p tr
end=
0.00
4
N
otes
. BM
I: b
ody
mas
s in
dex,
kca
l: H
RT:
horm
one
repl
acem
ent
ther
apy,
kilo
calo
ries,
kg:
kilo
gram
, km
: ki
lom
eter
s, m
: m
iles,
MET
: m
etab
olic
eq
uiva
lent
, MI:
myo
card
ial i
nfar
ctio
n, m
PA:
mod
erat
e in
tens
ity p
hysi
cal a
ctiv
ity, P
A: ph
ysic
al a
ctiv
ity, S
BP:
syst
olic
blo
od p
ress
ure,
vPA
: vi
goro
us P
A
168
AP
PEN
DIX
C
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Ges
tati
onal
Dia
bete
s.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
Dem
psey
, et
al.,
(2
004)
OM
EGA
Stud
y (U
SA)
N=
909
18
-35
year
s of
age
(n
=65
9)
>35
yea
rs o
f ag
e (n
=25
0)
Inte
rvie
w:
199
6-20
00
�Ty
pe, f
requ
ency
and
dur
atio
n of
rec
reat
iona
l PA
done
in y
ear
prio
r to
pre
gnan
cy
�Ty
pe, f
requ
ency
and
dur
atio
n of
rec
reat
iona
l PA
done
in p
rior
wee
k U
sing
med
ian
valu
es a
s cu
t of
fs
�Av
erag
e PA
in y
ear
befo
re
preg
nanc
y (h
ours
/wee
k)
�Av
erag
e PA
ene
rgy
expe
nditu
re
year
bef
ore
preg
nanc
y (M
ET.h
ours
.wee
k)
�PA
tim
e du
ring
preg
nanc
y (h
ours
/wee
k)
�Av
erag
e PA
ene
rgy
expe
nditu
re
durin
g pr
egna
ncy
(MET
.hou
rs/w
eek)
7-9
mon
ths
age,
rac
e, p
arity
, pr
epre
gnan
cy B
MI
PA d
urin
g ye
ar p
rior
to p
regn
ancy
N
o PA
1.00
An
y PA
0.
44 (
0.21
–0.9
1)
PA y
ear
prio
r to
pre
gnan
cy (
hour
s/w
k)
No
PA
1.
00
<4.
2
0.58
(0.
27–1
.24)
>
4.2
0.
24 (
0.10
–0.6
4)
PA y
ear
prio
r to
pre
gnan
cy (
MET
.hou
rs/w
k)
Nil
1.
00
<21
.1
0.
57 (
0.27
–1.2
1)
>21
.1
0.
26 (
0.10
–0.6
5).
PA d
urin
g pr
egna
ncy
No
PA
1.
00
Any
PA
0.69
(0.
37–1
.29)
PA
dur
ing
preg
nanc
y (h
ours
/wk)
N
o PA
1.00
<
6.0
0.
49 (
0.21
–1.1
3)
>6.
0
0.90
(0.
45–1
.80)
169
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
PA d
urin
g pr
egna
ncy
(MET
.hou
rs/w
k)
Nil
1.
00
<28
0.71
(0.
35–1
.47)
>
28
0.
67 (
0.31
–1.4
3)
PA b
oth
befo
re a
nd d
urin
g pr
egna
ncy
No
PA
1.00
PA
last
yea
r on
ly
0.40
(0.
15-1
.07)
PA
last
wee
k on
ly
0.59
(0.
16-2
.14)
PA
bot
h pe
riods
0.
31 (
0.12
–0.7
9)
Dye
et
al.,
1997
U
SA
N=
12,
290
Inte
rvie
w:
1995
-96
�Av
erag
e fr
eque
ncy/
wee
k of
ex
erci
se f
or >
30 m
inut
es
durin
g pr
egna
ncy
9 m
onth
s Ag
e, r
ace,
par
ity,
prep
regn
ancy
BM
I,
gest
atio
nal w
eigh
t ga
in,
insu
ranc
e co
vera
ge
PA
Any
exer
cise
1.
00
No
exer
cise
1.
00
(0.8
-1.3
)
Solo
mon
, et
al.,
(1
997)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
14,
613
25-4
2 ye
ars
of a
ge
in 1
989
Que
stio
nnai
re:
1989
�
(pre
grav
id)
Freq
uenc
y an
d du
ratio
n of
wal
king
, jog
ging
, ru
nnin
g, b
icyc
ling,
ca
listh
enic
s/ae
robi
cs, l
ap
swim
min
g, o
ther
aer
obic
re
crea
tion
5 ye
ars
age,
fam
ily h
isto
ry o
f di
abet
es, p
regr
avid
BM
I,
ethn
icity
, par
ity
Preg
ravi
d PA
(M
ETs/
wk)
<
4
1.00
4-
9.9
1.
23 (
0.97
–1.5
6)
10-1
9.9
0.
99 (
0.77
– 1
.27)
20
-39.
9
0.97
(0.
76–1
.25)
>
40
0.
98 (
0.75
–1.2
8)
p tr
end=
0.26
170
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d,
Adju
stm
ents
Su
mm
ary
of R
esul
ts
(95%
con
fiden
ce in
terv
al)
�
(pre
grav
id)
Flig
hts
of s
tairs
cl
imbe
d da
ily
�(p
regr
avid
) U
sual
wal
king
pac
e �
Tota
l pre
grav
id P
A en
ergy
ex
pend
iture
(M
ETs/
wee
k)
�Pr
egra
vid
vigo
rous
PA
freq
uenc
y (x
/wee
k)
�U
sual
pre
grav
id w
alki
ng p
ace
(kilo
met
ers/
hour
)
Preg
ravi
d w
alki
ng p
ace
(km
/hou
r)
<3.
2
1.00
3.
2-4.
7
0.97
(0.
75–1
.26)
4.
8-6.
3
0.85
(0.
64–1
.12)
>
6.4
0.
85 (
0.55
–1.3
1)
p tr
end=
0.12
Pr
egra
vid
vPA
(fre
quen
cy/w
eek)
<
1
1.00
1-
3
0.99
(0.
63–1
.34)
>
4
0.78
(0.
47–1
.26)
p
tren
d=0.
63
N
ote:
BM
I: b
ody
mas
s in
dex;
km
: ki
lom
etre
, MET
: m
etab
olic
equ
ival
ent,
mPA
: m
oder
ate
inte
nsity
phy
sica
l act
ivity
, PA:
ph
ysic
al a
ctiv
ity, v
PA:
vigo
rous
PA
.
171
AP
PEN
DIX
D
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Bre
ast
Canc
er.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Bres
low
et
al.,
(200
1)
Epid
emio
logi
cal
Follo
w u
p St
udy
(NH
EFS)
of th
e Fi
rst
Nat
iona
l H
ealth
and
N
utrit
ion
Exam
inat
ion
Surv
ey
(USA
) N
= 6
,160
24
-75
year
s of
ag
e in
197
1-75
Inte
rvie
w:
1971
-75,
198
2-84
�
Self
ratin
g of
rec
reat
ion
exer
cise
am
ount
: m
uch,
m
oder
ate,
litt
le o
r no
exe
rcis
e �
Com
bina
tion
of P
A le
vel a
t 19
71-7
5 an
d 19
82-8
4:
Cons
iste
ntly
low
(lo
w a
t bo
th
times
), c
onsi
sten
tly h
igh
(hig
h at
bot
h tim
es o
r m
oder
ate
at
one
time
and
high
at
the
othe
r), m
oder
ate/
inco
nsis
tent
(a
ll ot
hers
)
10 y
ears
BM
I, a
dult
wei
ght
chan
ge,
adul
t w
eigh
t ga
in,
educ
atio
n, a
ge a
t m
enar
che,
par
ity,
men
stru
al s
tatu
s, f
amily
hi
stor
y br
east
can
cer
PA le
vel,
all w
omen
Co
nsis
tent
ly lo
w
1.00
M
oder
ate/
inco
nsis
tent
0.
92 (
0.62
-1.3
8)
Cons
iste
ntly
hig
h 0.
58 (
0.31
-1.0
7)
p tr
end=
0.10
7 PA
leve
l, w
omen
age
d <
50 y
ears
Co
nsis
tent
ly lo
w
1.00
M
oder
ate/
inco
nsis
tent
1.
07 (
0.46
-2.5
1)
Cons
iste
ntly
hig
h 1.
19 (
0.43
-3.3
0)
p tr
end=
0.73
2 PA
leve
l, w
omen
age
d >
50 y
ears
Co
nsis
tent
ly lo
w
1.00
M
oder
ate/
inco
nsis
tent
0.
87 (
0.55
-1.3
8)
Cons
iste
ntly
hig
h 0.
33 (
0.14
-0.8
2)
p tr
end=
0.02
6
172
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Lee,
Rex
rode
, Co
ok,
Hen
neke
ns
et a
l.,
(200
1)
Wom
en's
Hea
lth
Stud
y (U
SA)
N=
39,
322
>45
yea
rs o
f ag
e
Que
stio
nnai
re:
1992
-95
�Av
erag
e w
eekl
y tim
e ov
er p
ast
year
spe
nt w
alki
ng/h
ikin
g,
jogg
ing,
run
ning
, cyc
ling,
ae
robi
cs, l
ow in
tens
ity
exer
cise
, rac
ket
spor
ts,
swim
min
g �
Usu
al w
alki
ng p
ace
�N
umbe
r of
flig
hts
of s
tairs
cl
imbe
d da
ily
�PA
ene
rgy
expe
nditu
re
quar
tiles
(ki
lojo
ules
/wee
k)
�Vi
goro
us P
A en
ergy
ex
pend
iture
(ki
lojo
ules
/wee
k)
Aver
age
2 ye
ars
BMI,
alc
ohol
, men
arch
e ag
e, a
ge a
t fir
st p
regn
ancy
la
stin
g >
6mo,
num
ber
of
preg
nanc
ies
last
ing
>6m
o,
oral
con
trac
eptiv
e, p
ost
men
opau
sal h
orm
ones
, fa
mily
his
tory
of
brea
st
canc
er
PA (
kj/w
k), a
ll w
omen
<
840
1.
00
840-
2519
1.
04 (
0.77
-1.4
0)
2520
-629
9 0.
86 (
0.64
-1.1
7)
>63
00
0.
80 (
0.58
-1.1
2)
p tr
end=
0.11
vP
A (k
j/w
k), a
ll w
omen
no
ne
1.
00
1-83
9
1.02
(0.
70-1
.48)
84
0-20
99
1.11
(0.
78-1
.58)
21
00-4
199
0.97
(0.
66-1
.44)
>
4200
0.98
(0.
69-1
.40)
p
tren
d=0.
9 PA
(kj
/wk)
, pos
t m
enop
ausa
l wom
en
<84
0
1.00
84
0-25
19
0.97
(0.
68-1
.39)
25
20-6
299
0.78
(0.
54-1
.12)
>
6300
0.67
(0.
44-1
.02)
p
tren
d=0.
03
173
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
vPA
(kj/
wk)
, pos
t m
enop
ausa
l wom
en
none
1.00
1-
839
0.
93 (
0.57
-1.5
0)
840-
2099
0.
91 (
0.57
-1.4
7)
2100
-419
9 0.
93 (
0.57
-1.5
0)
>42
00
0.
76 (
0.47
-1.2
4)
p tr
end=
0.29
Luot
o, e
t al
., (2
000)
Fi
nnis
h Ad
ult
Hea
lth B
ehav
iour
Su
rvey
(Fi
nlan
d)
N=
30,
548
15-6
4 ye
ars
of
age
Que
stio
nnai
re:
annu
ally
197
8-93
(n
ot 1
985)
�
Freq
uenc
y of
leis
ure
exer
cise
fo
r >
30m
ins
�M
inut
es w
alki
ng/c
yclin
g co
mm
utin
g to
wor
k �
Leis
ure
PA fre
quen
cy/w
eek
�Co
mm
utin
g PA
�
PA le
vel (
LTPA
and
com
mut
ing
PA)
<16
yea
rs
educ
atio
n, p
arity
and
age
at
firs
t bi
rth,
BM
I
Leis
ure
PA (
x/w
k), a
ll w
omen
<
1
1.00
1
0.
80 (
0.58
-1.1
0)
2-3
0.
92 (
0.78
-1.2
2)
Dai
ly
1.
01 (
0.72
-1.4
2)
Com
mut
ing
PA, a
ll w
omen
N
o w
ork/
at h
ome
1.00
N
o PA
, car
0.
94 (
0.66
-1.3
4)
<30
min
s/da
y 0.
89 (
0.67
-1.1
8)
>30
min
s/da
y 0.
87 (
0.62
-1.2
4)
PA le
vel (
LTPA
and
com
mut
ing
PA)
Mos
t ac
tive
1.00
Le
ast
activ
e 1.
01 (
0.80
-1.2
9)
174
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Leis
ure
PA (
x/w
k), a
ged
<50
yea
rs
<1
1.
00
1
0.98
(0.
61-1
.58)
2-
3
0.92
(0.
58-1
.44)
D
aily
1.25
(0.
70-1
.22)
Co
mm
utin
g PA
, age
d <
50 y
ears
N
o w
ork/
at h
ome
1.00
N
o PA
, car
1.
11 (
0.66
-1.8
9)
<30
min
s/da
y 1.
07 (
0.60
-1.6
8)
>30
min
s/da
y 0.
72 (
0.38
-1.3
6)
Leis
ure
PA (
x/w
k), a
ged
>50
yea
rs
<1
1.
00
1
0.71
(0.
46-1
.10)
2-
3
0.96
(0.
68-1
.36)
D
aily
0.97
(0.
65-1
.44)
Co
mm
utin
g PA
, age
d >
50 y
ears
N
o w
ork/
at h
ome
1.00
N
o PA
. car
0.
88 (
0.55
-1.3
9)
<30
min
s/da
y 0.
84 (
0.60
-1.1
6)
>30
min
s/da
y 1.
10 (
0.69
-1.5
0)
175
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
McT
iern
anet
al
., (2
003)
W
omen
's H
ealth
In
itiat
ive
Obs
erva
tiona
l St
udy
(USA
) N
= 7
4,17
1 50
-79
year
s of
ag
e in
199
3
Que
stio
nnai
re:
1993
-8
�O
ccur
renc
e of
str
enuo
us P
A >
3x w
eek
at a
ge 1
8, 3
5, 5
0 ye
ars
�Fr
eque
ncy,
dur
atio
n an
d sp
eed
of w
alki
ng o
utsi
de t
he h
ome
�Cu
rren
t fr
eque
ncy,
dur
atio
n of
st
renu
ous
exer
cise
, mod
erat
e ex
erci
se, l
ow in
tens
ity e
xerc
ise
�Vi
goro
us P
A >
3x/w
eek
at a
ge
18 y
ears
, 35
year
s, 5
0 ye
ars
�
Tota
l PA
ener
gy e
xpen
ditu
re
(MET
.hou
r/w
eek)
�
mod
erat
e PA
+ v
igor
ous
PA
time
(hou
rs/w
eek)
�
vigo
rous
PA
time
(hou
rs/w
eek)
Appr
ox 6
yea
rs
Mea
n 4.
7 ye
ars
1993
-199
8 ag
e, B
MI,
HRT
, rac
e,
geog
raph
ic r
egio
n, in
com
e,
educ
atio
n, e
ver
brea
stfe
d,
hyst
erec
tom
y st
atus
, fa
mily
his
tory
bre
ast
canc
er, s
mok
ing,
par
ity,
age
at f
irst
birt
h,
mam
mog
ram
fre
quen
cy,
alco
hol,
men
arch
e ag
e,
men
opau
se a
ge.
vPA
>3x
/wee
k at
18
year
s of
age
no
1.
00
yes
0.94
(0.
85-1
.04)
p=
0.21
vP
A >
3x/w
eek
at 3
5 ye
ars
of a
ge
no
1.00
ye
s 0.
86 (
0.78
-0.9
5)
p=0.
003
vPA
>3x
/wee
k at
50
year
s of
age
no
1.
00
yes
0.92
(0.
83-1
.01)
p=
0.08
To
tal P
A (M
ET.h
r/w
k)
Non
e
1.00
<
5
0.90
(0.
77-1
.07)
5.
1-10
0.82
(0.
68-0
.97)
10
.1-2
0
0.89
(0.
76-1
.00)
21
.1-4
0
0.83
(0.
70-0
.98)
>
40
0.
78 (
0.62
-1.0
0)
p tr
end=
0.03
176
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
mPA
+ v
PA (
hrs/
wk)
no
ne
1.
00
<1
0.
92 (
0.78
–1.1
0)
1.1-
2
0.91
(0.
79-1
.10)
2.
1-3
0.
94 (
0.81
-1.1
0)
3.1-
4
0.99
(0.
83-1
.20)
4.
1-7
0.
91 (
0.78
-1.1
0)
>7
0.
79 (
0.63
-0.9
9)
p tr
end=
0.12
vP
A (h
rs/w
k)
Non
e
1.00
<
1
0.94
(0.
80-1
.10)
1.
1-2
0.
95 (
0.80
-1.1
0)
2.1-
4
0.93
(0.
78-1
.10)
>
4
0.91
(0.
67-1
.20)
p
tren
d=0.
25
177
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Moo
re, e
t al
., (2
000)
Io
wa
Wom
en's
H
ealth
Stu
dy
(USA
) N
= 3
7,10
5 55
-69
year
s of
ag
e in
198
6
Que
stio
nnai
re:
1986
�
Any
regu
lar
PA t
o ke
ep f
it �
Freq
uenc
y of
mod
erat
e PA
(in
clud
ing
gard
enin
g an
d w
alki
ng)
�Fr
eque
ncy
of v
igor
ous
PA
�PA
leve
l: lo
w (
vPA
<1
x/w
eek
OR
mPA
<1
x/w
eek)
, med
ium
(v
PA 1
x/w
eek
OR
mPA
1-
4x/w
eek)
, hig
h (v
PA >
2x/w
eek
OR
mPA
>4x
/wee
k)
�An
y re
gula
r PA
�
Mod
erat
e PA
fre
quen
cy
�Vi
goro
us P
A fr
eque
ncy
9 ye
ars
age,
age
at
men
opau
se,
age
at f
irst
live
birt
h, B
MI
at a
ge 1
8yea
rs, e
duca
tion,
fa
mily
his
tory
of
brea
st
canc
er, e
stro
gen,
wai
st t
o hi
p ra
tio, B
MI,
BM
I sq
uare
d
PA le
vel
Low
1.00
M
ediu
m 1
.12
(0.9
9-1.
28)
Hig
h
0.95
(0.
83-1
.10)
An
y re
gula
r PA
N
o
1.00
Ye
s
0.99
(0.
89-1
.11)
m
PA f
requ
ency
ra
rely
/nev
er
1.00
fe
w x
/mon
th
1.03
(0.
88-1
.20)
2-
4 x/
wk
1.08
(0.
92-1
.26)
>
4 x/
wk
0.92
(0.
77-1
.10)
vP
A fr
eque
ncy
rare
ly/n
ever
1.
00
few
x/m
onth
1.
25 (
1.04
-1.5
0)
2-4
x/w
k 1.
14 (
0.92
-1.4
3)
>4
x/w
k 1.
05 (
0.72
-1.5
2)
178
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Rock
hill,
et
al.,
(199
8)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
104
,468
25
-42y
ears
of
age
in 1
989
Que
stio
nnai
re:
1989
�
Mon
ths/
year
do
stre
nuou
s PA
fo
r >
2/w
eek
whi
le in
hig
h sc
hool
and
whe
n ag
ed 1
8-22
ye
ars
�Av
erag
e tim
e/w
eek
in p
ast
year
wal
king
/hik
ing,
jogg
ing,
ru
nnin
g, b
icyc
ling,
lap
swim
min
g, r
acke
t sp
orts
, ae
robi
cs, r
owin
g m
achi
ne,
othe
r ae
robi
c PA
(eg
law
n m
owin
g)
�U
sual
wal
king
pac
e �
Vigo
rous
PA
freq
uenc
y du
ring
high
sch
ool a
nd a
ges
18-2
2 ye
ars
(mon
ths/
year
)
�M
oder
ate
PA +
vig
orou
s PA
+
bris
k w
alki
ng (
hour
s/w
eek)
6 ye
ars
base
line
age,
men
arch
e ag
e, h
isto
ry o
f be
nign
br
east
dis
ease
, fam
ily
hist
ory
brea
st c
ance
r,
alco
hol,
heig
ht, o
ral
cont
race
ptiv
e, p
arity
and
ag
e of
firs
t bi
rth
vPA
freq
uenc
y du
ring
high
sch
ool a
nd a
t ag
e 18
-22
yea
rs (
mon
ths/
year
) ne
ver
1.
0 1-
3
0.9
(0.6
-1.2
) 4-
6
1.1
(0.8
-1.4
) 7-
9
1.1
(0.8
-1.5
) 10
-12
1.
1 (0
.8-1
.6)
mPA
+ v
PA +
wal
king
(hr
s/w
k)
<1
1.
0 1.
0-1.
9
1.1
(0.8
-1.4
) 2.
0-3.
0
1.1
(0.8
-1.4
) 4.
0-6.
9
1.0
(0.7
-1.4
) >
7
1.1
(0.8
-1.5
)
Rock
hill,
et
al.,
(199
9)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
85,
364
(198
0 da
ta)
Que
stio
nnai
re
�19
80:
Ave
rage
hou
rs/w
eek
in
recr
eatio
nal m
oder
ate
and
vigo
rous
PA
incl
udin
g ga
rden
ing,
vig
orou
s sp
orts
, jo
ggin
g, b
risk
wal
king
, bi
cycl
ing,
hea
vy h
ouse
wor
k et
c �
1982
: a
vera
ge h
ours
/wee
k of
16 y
ears
ba
selin
e ag
e, m
enar
che
age,
his
tory
ben
ign
brea
st
dise
ase,
fam
ily h
isto
ry
brea
st c
ance
r, h
eigh
t,
parit
y an
d ag
e fir
st b
irth,
BM
I at
18y
rs, m
enop
ausa
l
Cum
ulat
ive
aver
age
vPA
or m
PA (
hrs/
wk)
<
1.0
1.
00
1.0-
1.9
0.
88 (
0.79
-0.9
8)
2.0-
3.9
0.
89 (
0.81
-0.9
9)
4.0-
6.0
0.
85 (
0.77
-0.9
4)
>7.
0
0.82
(0.
70-0
.97)
p
tren
d=0.
004
179
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
N=
77,
024
(1
986
data
) 30
-55
year
s of
ag
e in
197
6
stre
nuou
s PA
�
1986
, 198
8, 1
992,
199
4:
aver
age
time/
year
in
wal
king
/hik
ing,
jogg
ing,
ru
nnin
g, c
yclin
g, la
p sw
imm
ing,
ten
nis/
squa
sh,
aero
bics
, row
ing
mac
hine
�
1986
, 198
8, 1
992,
199
4: U
sual
w
alki
ng p
ace
(exc
lude
d if
not
bris
k)
�Cu
mul
ativ
e av
erag
e of
vi
goro
us P
A or
mod
erat
e PA
up
date
d ev
ery
two
year
s 19
80-
1994
(ho
urs/
wee
k)
�Vi
goro
us P
A or
mod
erat
e PA
at
1980
bas
elin
e (h
ours
/wee
k)
�Cu
mul
ativ
e av
erag
e vi
goro
us
PA 1
986-
1994
(ho
urs/
wee
k)
stat
us, p
ost
men
opau
sal
horm
one
use.
vPA
or m
PA a
t 19
80 (
hrs/
wk)
<
1
1.00
1.
0-1.
9
1.03
(0.
90-1
.17)
2.
0-3.
9
0.97
(0.
88-1
.07)
4.
0-6.
0
0.90
(0.
80-1
.01)
>
7.0
0.
89 (
0.80
-0.9
8)
p tr
end=
0.00
4 vP
A 19
86-1
994
(hrs
/wk)
<
1.0
1.
00
1.0-
1.9
0.
95 (
0.83
-1.0
9)
2.0-
3.9
0.
85 (
0.71
-1.0
3)
4.0-
6.0
0.
90 (
0.70
-1.1
6)
>7.
0
0.87
(0.
71-1
.06)
p
tren
d=0.
11
Sess
o et
al.,
(1
998)
Pe
nnsy
lvan
ia
Colle
ge A
lum
ni
Hea
lth S
tudy
(U
S)
N=
1,5
66
Que
stio
nnai
re:
1962
�
Num
ber
of f
light
s of
sta
irs
clim
bed
daily
�
Num
ber
of c
ity b
lock
s w
alke
d da
ily
�H
ours
/wee
k in
spo
rts
31 y
ears
ag
e, B
MI
Tota
l PA
(kca
l/wk)
, all
wom
en
<50
0
1.00
50
0-99
9 0.
92 (
0.58
-1.4
5)
>10
00
0.
73 (
0.46
-1.1
4)
p tr
end=
0.17
180
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
37-6
9 ye
ars
of
age
Mea
n ag
e 45
.5
year
s
�To
tal P
A en
ergy
exp
endi
ture
te
rtile
s (k
cal/w
eek)
Tota
l PA
(kca
l/wk)
, <55
yea
rs o
f ag
e <
500
1.
00
500-
999
0.81
(0.
27-2
.47)
>
1000
1.83
(0.
77-4
.31)
p
tren
d=0.
41
Tota
l PA
(kca
l/wk)
, >55
yea
rs o
f ag
e (k
cal/w
k)
<50
0
1.00
50
0-99
9 0.
95 (
0.58
-1.5
7)
>10
00
0.
49 (
0.28
-0.8
6)
p tr
end=
0.01
5
Teha
rd, e
t al
., (2
006)
E3
N S
tudy
(F
ranc
e)
90,0
59
40-6
5 ye
ars
of
age
in 1
990
Que
stio
nnai
re:
1990
-1
�U
sual
dis
tanc
e w
alke
d da
ily
�Av
erag
e nu
mbe
r of
flig
hts
of
stai
rs c
limbe
d da
ily
�Av
erag
e tim
e/w
eek
light
ho
useh
old
PA, h
eavy
ho
useh
old
PA
�Av
erag
e tim
e/w
eek
mod
erat
e re
crea
tiona
l PA,
vig
orou
s re
crea
tiona
l PA
12 y
ears
BM
I, m
enop
ausa
l sta
tus,
ho
rmon
e re
plac
emen
t th
erap
y, a
ge a
t m
enar
che,
ag
e at
firs
t fu
ll te
rm
preg
nanc
y, p
arity
, mar
ital
stat
us, u
se o
f or
al
cont
race
ptiv
es, f
amily
hi
stor
y of
bre
ast
canc
er,
pers
onal
his
tory
of
beni
gn
brea
st d
isea
se e
mpl
oym
ent
Wal
king
(m
/day
) <
500
1.
00
500-
2000
1.
03 (
0.95
-1.1
1)
>20
00
0.
91 (
0.81
-1.0
2)
p tr
end=
0.45
St
airs
clim
bed
(num
ber/
day)
0
1.
00
1-4
0.
99 (
0.90
-1.0
8)
>5
1.
00 (
0.90
-1.1
2)
p tr
end=
0.84
181
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�U
sual
dis
tanc
e w
alke
d (m
etre
s/da
y)
�Av
erag
e st
airs
clim
bed
(num
ber/
day)
�
Ligh
t ho
useh
old
PA
(hou
rs/w
eek)
�
Hea
vy h
ouse
hold
PA
(hou
rs/w
eek)
�
Mod
erat
e PA
(ho
urs/
wee
k)
�Vi
goro
us P
A (h
ours
/wee
k)
�To
tal r
ecre
atio
nal P
A (in
clud
es
wal
king
) (M
ET.h
ours
/wee
k)
�To
tal P
A (r
ecre
atio
n +
wal
king
+
sta
irs +
hou
seho
ld)
(MET
.hou
rs/w
eek)
Li
ght
hous
ehol
d PA
(hr
s/w
k)
0
1.00
1-
4
1.02
(0.
82-1
.28)
5-
13
0.
95 (
0.75
-1.2
0)
>14
0.82
(0.
61-1
.11)
p
tren
d <
0.05
H
eavy
hou
seho
ld P
A (h
rs/w
k)
inac
tive
1.
00
1-2
0.
98 (
0.89
-1.0
7)
3-4
0.
94 (
0.84
-1.0
6)
>5
0.
97 (
0.81
-1.1
5)
p tr
end=
0.47
m
PA (
hrs/
wk)
in
activ
e
1.00
0
0.
80 (
0.60
-1.0
5)
1-4
0.
87 (
0.79
-0.9
4)
5-13
0.86
(0.
74-0
.99)
>
14
0.
89 (
0.65
-1.2
4)
p tr
end
<0.
01
182
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
vPA
(hrs
/wk)
in
activ
e
1.00
0
0.
90 (
0.81
-0.9
9)
1-2
0.
88 (
0.79
-0.9
7)
3-4
0.
82 (
0.71
– 0
.95)
>
5
0.62
(0.
49-0
.78)
p
tren
d <
0.00
01.
Tota
l rec
reat
iona
l PA
(MET
.hrs
/wk)
in
activ
e
1.00
<
16
0.
82 (
0.71
-0.9
3)
16-2
2.3
0.
94 (
0.84
-1.0
6)
22.3
-33.
8 0.
88 (
0.79
-0.9
8)
>33
.8
0.
81 (
0.72
-0.9
2)
p tr
end
<0.
01
Tota
l PA
(MET
.hrs
/wk)
<
28.3
1.00
28
.3-4
1.8
1.05
(0.
93-1
.17)
41
.8-5
7.8
0.94
(0.
83-1
.05)
>
57.8
0.90
(0.
80-1
.02)
p
tren
d <
0.05
183
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Thun
e, e
t al
., (1
997)
N
atio
nal H
ealth
Sc
reen
ing
Serv
ice
(Nor
way
) N
=25
,624
20
–54
year
s of
ag
e in
197
4-19
78
Que
stio
nnai
re:
1974
-78,
197
7-83
�
Leve
l of PA
dur
ing
leis
ure
time
durin
g pr
evio
us y
ear
�Le
vel o
f oc
cupa
tiona
l act
ivity
du
ring
prev
ious
yea
r �
Leis
ure
PA le
vel (
both
su
rvey
s):
sede
ntar
y, m
oder
ate
(<4
hour
s/w
eek
wal
king
, cy
clin
g, d
oing
PA)
, reg
ular
ex
erci
se (
<4
hour
s/w
eek
exer
cisi
ng f
or f
itnes
s or
re
crea
tiona
l ath
letic
s O
R re
gula
r vi
goro
us t
rain
ing
or
com
petit
ive
spor
ts s
ever
al
times
a w
eek)
. �
Occ
upat
iona
l PA
(1st s
urve
y):
sede
ntar
y, w
alki
ng, l
iftin
g an
d w
alki
ng, h
eavy
man
ual l
abou
r �
Leis
ure
PA (
both
sur
veys
):
cons
iste
ntly
sed
enta
ry
(sed
enta
ry b
oth
times
),
cons
iste
ntly
act
ive
(mod
erat
e or
reg
ular
tim
e 1
& r
egul
ar
time
2), m
oder
atel
y ac
tive
(all
othe
rs)
1994
M
edia
n fo
llow
up
of 1
3.7
year
s ag
e, B
MI,
hei
ght,
par
ity,
coun
ty o
f re
side
nce,
nu
mbe
r of
chi
ldre
n
.
Leis
ure
PA le
vel (
1st s
urve
y)
Sede
ntar
y 1.
00
Mod
erat
e 0.
93 (
0.71
-1.2
2)
Regu
lar
exer
cise
0.6
3 (0
.42-
0.95
) p
tren
d=0.
04
Occ
upat
iona
l PA
(1st s
urve
y)
Sede
ntar
y 1.
00
Wal
king
0.
84 (
0.63
-1.1
2)
Lift
ing
& w
alki
ng
0.74
(0.
52-1
.06)
H
eavy
labo
ur
0.48
(0.
25-0
.92)
p
tren
d=0.
02
Leis
ure
PA le
vel (
1st s
urve
y), p
rem
enop
ausa
l w
omen
Se
dent
ary
1.00
M
oder
ate
0.77
(0.
46-1
.27)
Reg
ular
exe
rcis
e 0.
53 (
0.25
-1.1
4)
p tr
end=
0.10
Le
isur
e PA
leve
l, oc
cupa
tiona
l PA,
(1st
sur
vey)
Se
dent
ary
1.00
W
alki
ng
0.82
(0.
50-1
.34)
Li
ftin
g &
wal
king
0.
48 (
0.24
-0.9
5)
p tr
end=
0.03
184
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Leis
ure
PA (
1st s
urve
y), p
ost
men
opau
sal w
omen
Se
dent
ary
1.00
M
oder
ate
1.00
(0.
72-1
.39)
Reg
ular
exe
rcis
e 0.
67 (
0.41
-1.1
0)
p tr
end=
0.15
Le
isur
e PA
(1st
sur
vey)
, occ
upat
iona
l PA
(1st
surv
ey)
Sede
ntar
y 1.
00
Mod
erat
e 0.
87 (
0.61
-1.2
4)
Reg
ular
exe
rcis
e 0.
78 (
0.52
-1.1
8)
p tr
end=
0.24
Le
isur
e PA
(co
mpa
ring
surv
eys)
co
nsis
tent
ly s
eden
tary
1.
00
mod
erat
ely
activ
e 0.
90 (
0.61
-1.3
2)
cons
iste
ntly
act
ive
0.67
(0.
40-1
.10)
p
tren
d=0.
09
N
otes
. BM
I: b
ody
mas
s in
dex,
HRT:
hor
mon
e re
plac
emen
t th
erap
y, k
cal:
kilo
calo
ries,
kj:
kilo
joul
es, k
g: k
ilogr
am, k
m:
kilo
met
ers,
m:
mile
s,
MET
: m
etab
olic
equ
ival
ent,
mPA
: m
oder
ate
inte
nsity
phy
sica
l act
ivity
, PA:
ph
ysic
al a
ctiv
ity, v
PA:
vigo
rous
PA
185
AP
PEN
DIX
E
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Colo
n an
d Co
lore
ctal
Can
cer.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Chao
, et
al.,
(200
4)
Canc
er P
reve
ntio
n St
udy
II N
utrit
ion
Coho
rt (
USA
) N
= 8
0,77
1 50
-74
year
s of
age
in
199
2 M
edia
n ag
e 63
ye
ars
Que
stio
nnai
re (
1992
-3)
�Av
erag
e ho
urs
per
wee
k in
pr
evio
us y
ear
spen
t w
alki
ng,
jogg
ing/
runn
ing,
lap
swim
min
g, r
acke
t sp
orts
, cy
clin
g, a
erob
ics,
dan
cing
�
Part
icip
atio
n in
any
PA
�PA
tim
e (h
ours
/wee
k)
�PA
ene
rgy
expe
nditu
re
(MET
.hou
rs/w
eek)
�
Wal
king
tim
e (h
ours
/wee
k)
�W
alki
ng +
oth
er P
A tim
e (h
ours
/wee
k)
Inci
dent
col
on a
nd r
ecta
l ca
ncer
, 199
7, 1
999
7 ye
ars
age,
edu
catio
n, h
isto
rical
PA,
sm
okin
g, a
lcoh
ol u
se, r
ed
mea
t, fol
ate,
fib
re,
mul
tivita
min
s, H
RT
Any
PA
No
1.
00
Yes
0.
98 (
0.70
-1.3
7)
PA t
ime
(hou
rs/w
eek)
N
one
1.
00
<2
1.
01 (
0.70
-1.4
4)
2-3
1.
01 (
0.68
-1.4
9)
4-6
0.
97 (
0.66
-1.4
3)
7
1.03
(0.
65-1
.65)
>
8
0.65
(0.
39-1
.11)
p
tren
d=0.
14
PA (
MET
.hrs
/wee
k)
Non
e
1.00
>
7
1.02
(0.
71-1
.46)
7-
13
0.
98 (
0.65
-1.4
7)
14-2
3
1.00
(0.
68-1
.47)
24
-29
0.
94 (
0.60
-1.4
8)
>30
0.77
(0.
48-1
.24)
p
tren
d=0.
15
186
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Wal
king
tim
e (h
rs/w
k)
No
activ
ity
1.00
<
4
1.00
(0.
70-1
.44)
4-
6
1.08
(0.
71-1
.63)
>
7
1.18
(0.
71-1
.95)
p
tren
d=0.
41
Wal
king
+ o
ther
PA
time
(hrs
/wk)
N
o ac
tivity
1.
00
<4
0.
99 (
0.67
-1.4
7)
4-6
0.
72 (
0.43
-1.1
9)
>7
0.
59 (
0.36
-0.9
8)
p tr
end=
0.07
Lund
N
ilsen
&
Vatt
en
(200
1)
Nor
d-Tr
onde
lag
Hea
lth S
urve
y (N
orw
ay)
N=
38,
244
>20
yea
rs o
f ag
e in
198
4-86
Que
stio
nnai
re
�H
ow o
ften
do
you
exer
cise
�
How
long
do
your
exe
rcis
e �
How
har
d do
you
exe
rcis
e �
PA f
requ
ency
(x/
wee
k)
�PA
inde
x ba
sed
on
freq
uenc
y, in
tens
ity, a
nd
dura
tion
(ter
tiles
) (n
o va
lues
)
Inci
dent
can
cer
Met
asta
tic c
ance
r 12
yea
rs (
1995
) ag
e, B
MI,
dia
bete
s, b
lood
gl
ucos
e, m
arita
l sta
tus,
ed
ucat
ion
PA f
requ
ency
(x/
wee
k) f
or in
cide
nt c
ance
r <
1
1.00
1-
3
0.81
(0.
62-1
.05)
>
3
1.12
(0.
83-1
.52)
p=
0.85
PA
inde
x fo
r in
cide
nt c
ance
r Lo
wes
t te
rtile
1.
00
2nd t
ertil
e 0.
95 (
0.68
-1.3
3)
Hig
hest
ter
tile
0.81
(0.
54-1
.23)
p=
0.34
187
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
PA f
requ
ency
(x/
wee
k) f
or m
etas
tatic
can
cer
<1
1.
00
1-3
0.
71 (
0.49
-1.0
4)
>3
0.
95 (
0.61
-1.4
7)
p=0.
47
PA in
dex
for
met
asta
tic c
ance
r Lo
wes
t te
rtile
1.
00
2nd t
ertil
e 0.
73 (
0.44
-1.2
2)
Hig
hest
ter
tile
0.77
(0.
43-1
.38)
p=
0.34
Mar
tinez
, et
al.,
(1
997)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
67,
802
30
-55
year
s of
age
in
197
6
Que
stio
nnai
re (
1986
): le
isur
e �
Aver
age
time
per
wee
k in
pa
st y
ear
spen
t w
alki
ng/h
ikin
g, jo
ggin
g,
runn
ing,
cyc
ling,
lap
swim
min
g, r
acke
t sp
orts
, ae
robi
cs, r
owin
g m
achi
ne
�Av
erag
e w
eekl
y PA
(M
ET.h
ours
/wee
k)
�M
oder
ate
inte
nsity
PA
time
(hou
rs/d
ay)
�H
igh
inte
nsity
PA
(vPA
) tim
e (m
inut
es/d
ay)
6 ye
ars
1986
-199
2 ag
e, s
mok
ing,
fam
ily h
isto
ry
colo
rect
al c
ance
r, B
MI,
po
stm
enop
ausa
l hor
mon
e us
e, a
spiri
n, r
ed m
eat
inta
ke,
alco
hol
PA (
MET
.hrs
/wk)
<
2
1.00
2-
4
0.71
(0.
44-1
.15)
5-
10
0.
78 (
0.50
-1.2
0)
11-2
1
0.67
(0.
42-1
.07)
>
21
0.
54 (
0.33
-0.9
0)
p tr
end=
0.03
m
PA t
ime
(hrs
/day
) <
1
1.00
>
1
0.69
(0.
52-0
.90)
188
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�Li
ght
inte
nsity
PA
(LPA
) tim
e (h
ours
/day
)
vPA
time
(min
s/da
y)
<30
1.00
>
30
0.
61 (
0.43
-0.8
6)
LPA
time
(hrs
/day
) <
1
1.00
>
1
1.54
(0.
94-2
.50)
N
otes
. BM
I: b
ody
mas
s in
dex,
hr:
hou
r, H
RT:
horm
one
repl
acem
ent
ther
apy,
LPA
: lig
ht p
hysi
cal a
ctiv
ity, M
ET:
met
abol
ic e
quiv
alen
t, m
PA:
mod
erat
e in
tens
ity p
hysi
cal a
ctiv
ity, P
A: ph
ysic
al a
ctiv
ity, v
PA:
vigo
rous
PA,
wk:
wee
k
189
AP
PEN
DIX
F
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Canc
er (
Excl
udin
g B
reas
t an
d C
olor
ecta
l Can
cer)
.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Ande
rson
, et
al.,
(2
004)
Iow
a W
omen
's
Hea
lth S
tudy
(U
SA)
N=
31,
381
55-6
9 ye
ars
of a
ge
in 1
986
Que
stio
nnai
re:
1986
�
Asid
e fr
om w
ork
and
hom
e,
PA d
one
on d
aily
bas
is t
o ke
ep p
hysi
cally
fit
�Fr
eque
ncy
of m
PA (
e.g.
, bo
wlin
g, g
olf, li
ght
spor
ts,
gard
enin
g, lo
ng w
alks
) �
Freq
uenc
y of
vPA
(e.
g.,
jogg
ing,
rac
ket
spor
ts,
swim
min
g, a
erob
ics,
st
renu
ous
spor
ts)
�Pa
rtic
ipat
ion
in r
egul
ar P
A �
PA le
vel:
low
(vP
A <
1 x/
wee
k O
R m
PA <
1 x/
wee
k), m
ediu
m (
vPA
1x/w
eek
OR
mPA
1-
4x/w
eek)
, hig
h (v
PA
>2x
/wee
k O
R m
PA
>4x
/wee
k)
�m
PA f
requ
ency
�
vPA
freq
uenc
y
Ova
rian
canc
er
15 y
ears
ag
e, fam
ily h
isto
ry o
f ov
aria
n ca
ncer
, hys
tere
ctom
y st
atus
, nu
mbe
r liv
e bi
rths
, yea
rs s
mok
ing,
es
trog
en r
epla
cem
ent
ther
apy
Reg
ular
PA
No
1.00
Ye
s 1.
24 (
0.94
-1.6
3)
p tr
end=
0.12
PA
leve
l (/w
k)
Low
1.00
M
ediu
m 1
.14
(0.8
1-1.
60)
Hig
h
1.42
(1.
03-1
.97)
p
tren
d=0.
03
mPA
(/w
k)
rare
ly/n
ever
1.
00
1
0.75
(0.
50-1
.14)
2-
4
0.98
(0.
66-1
.44)
>
4
1.17
(0.
78-1
.75)
p
tren
d=0.
26
vPA
(/w
k)
rare
ly/n
ever
1.
00
1
0.84
(0.
50-1
.43)
2-
4
1.03
(0.
58-1
.80)
>
4
2.38
(1.
29-4
.38)
p
tren
d <
0.0
1
190
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Bert
one,
et
al.,
(200
1)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
92,8
25
30–5
5 ye
ars
of a
ge
in 1
976
Que
stio
nnai
re:
1980
�
hour
s/w
eekd
ay a
nd
/wee
kend
in v
igor
ous
PA
(e.g
., vi
goro
us s
port
, bris
k w
alki
ng, h
ill b
icyc
ling)
and
m
oder
ate
PA (
e.g.
, lev
el
bicy
clin
g, w
alki
ng, l
ight
sp
ort)
�
type
and
fre
quen
cy/w
eek
of
exer
cise
pro
duci
ng a
sw
eat
Que
stio
nnai
re:
1986
, 198
8,
1992
, 199
4
�tim
e/w
eek
jogg
ing,
run
ning
, bi
cycl
ing,
lap
swim
min
g,
rack
et s
port
s, a
erob
ics,
w
alki
ng/h
ikin
g �
usua
l wal
king
pac
e �
num
ber
fligh
ts o
f st
airs
cl
imbe
d da
ily
Que
stio
nnai
re:
1994
�
time/
wee
k lo
wer
inte
nsity
PA
e.g
., yo
ga, s
tret
chin
g �
time/
wee
k in
oth
er v
PA e
.g.
mow
ing
law
n
Ova
rian
canc
er
16 y
ears
ag
e, p
arity
, ora
l con
trac
eptio
n, t
ubal
lig
atio
n, m
enar
che
age,
hor
mon
e us
e, m
enop
ause
, sm
okin
g
1980
-199
6 cu
mul
ativ
e av
erag
e (h
rs/w
k)
<1.
00
1.
00
1-<
2
0.80
(0.
59-1
.08)
2-
<4
0.
86 (
0.65
-1.1
5)
4-<
7
1.10
(0.
82-1
.49)
>
7
0.80
(0.
49-1
.32)
p=
0.59
19
80 o
nly
(hrs
/wk)
<
1
1.00
1-
<2
0.
75 (
0.56
-1.0
2)
2-<
4
0.86
(0.
61-1
.20)
4-
<7
1.
01 (
0.73
-1.4
0)
>7
0.
92 (
0.62
-1.3
6)
p=0.
74
1986
-199
6 cu
mul
ativ
e av
erag
e (h
rs/w
k)
<1
1.
00
1-<
2
1.13
(0.
77-1
.65)
2-
<4
1.
10 (
0.76
-1.6
0)
4-<
7
0.98
(0.
64-1
.50)
>
7
1.26
(0.
80-1
.97)
p=
0.59
19
96 o
nly
(hrs
/wk)
<
1
1.00
1-
<2
1.
41 (
0.94
-2.1
1)
2-<
4
1.23
(0.
81-1
.85)
4-
<7
1.
12 (
0.69
-1.8
4)
>7
1.
64 (
1.05
-2.5
8)
p=0.
13
191
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�PA
leve
l 198
0, 1
986-
1996
, 19
86, a
vera
ge 1
980-
1986
(h
ours
/wee
k)
�PA
leve
l 198
0 in
tens
ity a
nd
freq
uenc
y: lo
w (
not
swea
ting)
, mPA
(<
5MET
s),
vPA
(>5
MET
S)
�To
tal P
A en
ergy
exp
endi
ture
cu
mul
ativ
e av
erag
e 19
86-
1996
(M
ET.h
ours
/wee
k)
�To
tal P
A en
ergy
exp
endi
ture
19
86 o
nly
(MET
.hou
rs/w
eek)
PA a
vera
ge 1
980-
1986
(hr
s/w
k)
<1
1.
00
1-<
2
0.72
(0.
48-1
.08)
2-
<4
1.
00 (
0.70
-1.4
3)
4-<
7
0.97
(0.
64-1
.45)
>
7
1.46
(0.
82-2
.60)
p=
0.18
PA
leve
l 198
0 (in
tens
ity a
nd f
requ
ency
) Lo
w
1.00
m
PA, <
2 x/
wk
0.
57 (
0.36
-0.9
2)
mPA
, 3-4
x/w
k
1.35
(0.
89-2
.03)
m
PA, >
4 x/
wk
0.
94 (
0.57
-1.5
4)
p tr
end=
0.93
vP
A, <
2 x/
wk
1.
05 (
0.68
-1.6
3)
vPA,
3-4
x/w
k
1.58
(1.
05-2
.38)
vP
A, >
4 x/
wk
1.
48 (
0.89
-2.4
8)
p tr
end=
0.03
To
tal P
A cu
mul
ativ
e av
erag
e 19
86-1
996
(MET
.hrs
/wk)
0-
<2.
5
1.00
2.
5-<
5.0
1.42
(0.
86-2
.34)
5.
0-<
10
1.34
(0.
83-2
.17)
10
-<20
1.
32 (
0.83
-2.1
0)
30-<
30
1.84
(1.
12-3
.02)
>
30
1.
27 (
0.75
-2.1
4)
p tr
end=
0.52
192
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Tota
l PA
ener
gy e
xpen
ditu
re 1
986
only
(M
ET.h
rs/w
k)
0-<
2.5
1.
00
2.5-
<5
1.
11 (
0.75
-1.6
6)
5-<
10
1.
30 (
0.89
-1.9
0)
10-<
20
1.02
(0.
68-1
.51)
20
-<30
1.
41 (
0.90
-2.1
8)
>30
1.16
(0.
75-1
.80)
p=
0.48
Gre
gg, e
t al
., (2
003)
St
udy
of
Ost
eopo
rotic
Fr
actu
res
(USA
) N
= 7
,553
>
65 y
ears
of
age
Que
stio
nnai
re:
1986
-198
8,
1992
-199
4 (m
edia
n pe
riod
5.7
year
s)
�N
umbe
r ci
ty b
lock
s or
eq
uiva
lent
wal
ked
daily
�
Freq
uenc
y an
d du
ratio
n of
le
isur
e ac
tiviti
es e
.g.
danc
ing,
gar
deni
ng,
swim
min
g, a
erob
ics
in p
ast
year
�
Sepa
rate
d w
alki
ng for
ex
erci
se a
nd o
ther
wal
king
�
Tota
l PA
ener
gy e
xpen
ditu
re
at b
asel
ine
quin
tiles
(k
cal/w
eek)
�
Wal
king
ene
rgy
expe
nditu
re
at b
asel
ine
quin
tiles
(k
cal/w
eek)
�
PA c
hang
e: se
dent
ary
–se
dent
ary
(<59
5 ka
l/wk)
,
Canc
er m
orta
lity
12.5
yea
rs
age,
sm
okin
g, B
MI,
str
oke,
dia
bete
s,
hype
rten
sion
, sel
f ra
ted
heal
th a
t ba
selin
e, c
ance
r, c
hron
ic o
bstr
uctiv
e pu
lmon
ary
dise
ase,
inci
dent
hip
fr
actu
re
Tota
l PA
(kca
l/wk)
<
163
1.
00
163-
503
0.77
(0.
60-0
.97)
50
4-10
45
0.90
(0.
71-1
.13)
10
46-1
906
0.62
(0.
48-0
.81)
>
1907
0.85
(0.
67-1
.09)
W
alki
ng (
kcal
/wk)
<
70
1.
00
70-1
86
1.08
(0.
85-1
.36)
18
7-41
9 0.
89 (
0.69
-1.1
5)
420-
897
0.90
(0.
70-1
.16)
>
898
0.
85 (
0.65
-1.1
0)
PA c
hang
e
Sede
ntar
y-se
dent
ary
1.00
Se
dent
ary-
activ
e 0.
49 (
0.29
-0.8
4)
Activ
e-se
dent
ary
0.61
(0.
42-0
.90)
Ac
tive-
activ
e
0.82
(0.
58-1
.16)
193
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
sede
ntar
y/ac
tive
(mov
ed
from
low
est
40%
to
high
est
60%
), a
ctiv
e/ s
eden
tary
(m
oved
fro
m h
ighe
st 6
0%
to lo
wes
t 40
%),
ac
tive/
activ
e
Kush
i, et
al
., (1
997)
Io
wa
Wom
en's
H
ealth
Stu
dy
(USA
) N
= 3
2,76
3 55
-69
year
s in
19
85
Que
stio
nnai
re:
1986
�
any
daily
leis
ure
time
PA
(not
occ
upat
iona
l or
dom
estic
) to
kee
p ph
ysic
ally
fit
�
freq
uenc
y an
d du
ratio
n of
m
oder
ate
PA (
incl
udin
g ga
rden
ing
and
wal
ks)
�fr
eque
ncy
and
dura
tion
of
vigo
rous
PA
�D
aily
PA
�M
oder
ate
PA fre
quen
cy
�Vi
goro
us P
A fr
eque
ncy
�PA
leve
l: lo
w (
vPA
<1x
/wee
k or
mPA
<
1x/w
eek)
, med
ium
(vP
A 1x
/wee
k or
mPA
1-
4x/w
eek)
, hig
h (v
PA
>2x
/wee
k or
mPA
>
4x/w
eek)
Canc
er m
orta
lity
7 ye
ars
age
at b
asel
ine,
age
at
men
arch
e,
age
at m
enop
ause
, age
at
first
live
bi
rth,
par
ity, a
lcoh
ol, t
otal
ene
rgy
inta
ke, s
mok
ing,
est
roge
n, B
MI
at
base
line,
BM
I at
age
18,
wai
st t
o hi
p ra
tio, e
duca
tion,
mar
ital s
tatu
s,
fam
ily h
isto
ry c
ance
r
Dai
ly P
A no
1.
00
yes
0.93
(0.
76-1
.14)
m
PA f
requ
ency
ra
rely
/nev
er
1.
00
few
/mon
th-1
x/w
k 0.
79 (
0.60
-1.0
3)
2-4
x/w
k
0.80
(0.
61-1
.05)
>
4 x/
wk
0.
85 (
0.63
-1.1
5)
p tr
end=
0.33
vP
A fr
eque
ncy
rare
ly/n
ever
1.00
fe
w/m
onth
-1 x
/wk
1.09
(0.
77-1
.53)
2-
4 x/
wk
0.
83 (
0.52
-1.3
3)
>4
x/w
k
0.69
(0.
31-1
.54)
p
tren
d=0.
28
PA le
vel
Low
1.00
M
ediu
m 0
.92
(0.7
2-1.
16)
Hig
h
0.94
(0.
73-1
.21)
p
tren
d=0.
64
194
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Mic
haud
, et
al.,
et
al.,
(200
1)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
117
, 041
30
-55
year
s of
age
Que
stio
nnai
re:
1986
�
Aver
age
time
per
wee
k du
ring
prev
ious
yea
r w
alki
ng/h
ikin
g, jo
ggin
g,
runn
ing,
cyc
ling,
lap
swim
min
g, r
acke
t sp
orts
, ca
lest
heni
cs/a
erob
ics.
�
Num
ber
fligh
ts o
f st
airs
cl
imbe
d da
ily
�To
tal P
A qu
intil
es
(MET
.hou
rs/w
eek)
�
Mod
erat
e PA
(w
alki
ng,
hiki
ng, s
tair
clim
bing
) qu
intil
es (
MET
.hou
rs/w
eek)
�
Vigo
rous
PA
quin
tiles
(M
ET.h
ours
/wee
k)
�W
alki
ng/h
ikin
g (t
ime/
wee
k)
Panc
reat
ic c
ance
r 10
-20
year
s he
ight
, age
gro
up, s
mok
ing,
di
abet
es h
isto
ry, c
hole
cyst
ecto
my,
pr
otei
n in
take
, die
tary
frui
t an
d ve
geta
bles
, cof
fee,
fat
inta
ke.
Tota
l PA
(MET
.hrs
/wk)
<
2.8
1.
00
2.9-
7.7
1.
00 (
0.56
-1.7
7)
7.8-
16.9
0.
84 (
0.46
-1.5
5)
17.0
-33.
9 0.
84 (
0.45
-1.6
5)
>34
.0
0.
78 (
0.42
-1.4
7)
p tr
end=
0.40
vP
A (M
ET.h
ours
/wk)
0
1.
00
0.2-
1.6
0.
66 (
0.34
-1.2
9)
1.7-
6.9
0.
64 (
0.31
-1.3
5)
7.0-
15.9
0.
76 (
0.41
-1.4
3)
>16
1.06
(0.
57-1
.96)
p
tren
d=0.
80
mPA
(M
ET.h
ours
/wk)
<
0.9
1.
00
0.9-
2.6
1.
01 (
0.56
-1.8
1)
2.7-
4.4
0.
85 (
0.47
-1.5
5)
4.5-
10.7
0.
85 (
0.46
-1.5
7)
>10
.8
0.
52 (
0.25
-1.0
5)
p tr
end=
0.05
W
alki
ng/h
ikin
g (/
wk)
<
20m
ins
1.00
20
-80m
ins
0.79
(0.
48-1
.30)
1.
5-3.
0 hr
s 0.
65 (
0.38
-1.1
3)
>4h
rs
0.
48 (
0.24
-0.9
7)
p tr
end=
0.04
195
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Mor
adi,
et
al.,
(199
8)
Nat
iona
l Cen
sus
(Sw
eden
) N
= 2
53,3
56
11-1
06 y
ears
of
age
in 1
971
Cens
us d
ata:
196
0, 1
970
�O
ccup
atio
nal g
roup
�
Occ
upat
iona
l PA
in 1
960,
19
70, a
nd b
oth
1960
/70:
ve
ry h
igh/
hig
h (e
.g.
clea
ners
, far
mer
s, d
ocke
rs),
m
ediu
m (
e.g.
mai
ds,
wai
ters
, nur
ses,
coo
ks),
ligh
t (t
each
ers,
hai
rdre
sser
s),
sede
ntar
y (e
.g. b
ook
keep
ers,
sec
reta
ries)
Endo
met
rial c
ance
r 18
yea
rs
age
at f
ollo
w u
p, p
lace
of
resi
denc
e,
year
of
follo
w u
p, s
ocio
econ
omic
st
atus
Occ
upat
iona
l PA
1960
Ve
ry h
igh/
high
1.
00
Med
ium
1.
03 (
0.94
-1.1
3)
Ligh
t
1.05
(0.
94-1
.16)
Se
dent
ary
1.13
(0.
99-1
.29)
p
tren
d=0.
11
Occ
upat
iona
l PA
1970
Ve
ry h
igh/
high
1.
00
Med
ium
1.0
2 (0
.95-
1.10
) Li
ght
1.
16 (
1.05
-1.2
7)
Sede
ntar
y 1.
32 (
1.17
-1.5
0)
p tr
end
<0.
001
Occ
upat
iona
l PA
sam
e in
196
0 an
d 19
70
Very
hig
h/hi
gh
1.00
M
ediu
m
1.04
(0.
89-1
.22)
Li
ght
1.
11 (
0.94
-1.3
1)
Sede
ntar
y 1.
30 (
1.03
-1.6
5)
p tr
end=
0.04
Pate
l, et
al
., (2
005)
Am
eric
an C
ance
r So
ciet
y Ca
ncer
Pr
even
tion
Stud
y II
Nut
ritio
n Co
hort
(U
SA)
N=
76,
038
50-7
4 ye
ars
of a
ge
in 1
992
Que
stio
nnai
re:
1982
�
how
muc
h ex
erci
se (
wor
k or
pl
ay)
Que
stio
nnai
re:
1992
�
Aver
age
time
per
wee
k du
ring
last
yea
r w
alki
ng,
jogg
ing/
runn
ing,
lap
swim
min
g, r
acke
t sp
orts
, bi
cycl
ing,
aer
obic
s, d
anci
ng
Panc
reat
ic c
ance
r 7
year
s ag
e, s
mok
ing,
yea
rs s
ince
qui
ttin
g sm
okin
g, e
duca
tion,
fam
ily h
isto
ry
panc
reat
ic c
ance
r, h
isto
ry
gallb
ladd
er d
isea
se, h
isto
ry d
iabe
tes,
to
tal c
alor
ic in
take
, bas
elin
e PA
(1
992)
Tota
l PA
(MET
.hrs
/wk)
N
one
1.
00
>0-
7
1.00
(0.
52-1
.91)
>
7-17
.5
0.62
(0.
30-1
.25)
>
17.5
-31.
5 0.
92 (
0.44
-1.8
9)
>31
.5
1.
42 (
0.59
-3.4
1)
p tr
end=
0.73
196
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�
At a
ge 4
0, a
vera
ge t
ime
per
wee
k du
ring
last
yea
r w
alki
ng, j
oggi
ng/r
unni
ng,
lap
swim
min
g, r
acke
t sp
orts
, bi
cycl
ing,
aer
obic
s, d
anci
ng
�To
tal P
A (M
ET.h
ours
/wee
k)
�To
tal P
A (M
ET.h
ours
/wee
k)
at a
ge 4
0 ye
ars
�Pa
st e
xerc
ise
amou
nt (
1982
) (n
ot q
uant
ified
)
To
tal P
A at
40
year
s of
age
(M
ET.h
rs/w
k)
Non
e
1.00
>
0-7
1.
15 (
0.64
-2.0
7)
>7-
17.5
0.
77 (
0.41
-1.4
6)
>17
.5-3
1.5
0.77
(0.
38-1
.53)
>
31.5
0.94
(0.
44-2
.03)
p
tren
d=0.
38
Exer
cise
in 1
982
Non
e/sl
ight
1.
00
Mod
erat
e 0.
84 (
0.54
-1.2
9)
Hea
vy
0.
97 (
0.40
-2.3
5)
p tr
end=
0.59
Rock
hill,
et
al.,
(200
1)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
80,
348
30
-55
year
s of
age
in
197
6
Que
stio
nnai
re:
1980
, 198
2,
1986
, 198
8, 1
992
�19
80:
aver
age
hour
s pe
r w
eek
durin
g la
st y
ear
in P
A (in
clud
ed s
port
s, jo
ggin
g,
gard
enin
g, w
alki
ng,
hous
ewor
k)
�19
82:
aver
age
hour
s pe
r w
eek
in s
tren
uous
PA
�19
86-1
992:
ave
rage
ho
urs/
wee
k pr
evio
us y
ear
wal
king
, jog
ging
, run
ning
, bi
cycl
ing,
sw
imm
ing,
rac
ket
spor
ts, a
erob
ics
�Cu
mul
ativ
e av
erag
e PA
(h
ours
/wee
k)
Canc
er m
orta
lity
14 y
ears
ag
e at
bas
elin
e, s
mok
ing,
rec
ent
alco
hol,
heig
ht, B
MI,
pos
t m
enop
ausa
l hor
mon
e us
e
PA (
hour
s/w
eek)
<
1
1.00
1-
1.9
0.
92 (
0.83
-1.0
2)
2.0-
3.9
0.
85 (
0.76
-0.9
4)
4.0-
6.9
0.
95 (
0.85
-1.0
7)
>7.
0
0.87
(0.
72-1
.04)
p
tren
d=0.
25
197
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Sinn
er, e
t al
., (2
005)
Io
wa
Wom
en's
H
ealth
Stu
dy
(USA
) N
=41
,836
55
-69
year
s of
age
in
198
5
Que
stio
nnai
re:
1986
�
any
daily
leis
ure
time
PA
(not
occ
upat
iona
l or
dom
estic
) to
kee
p ph
ysic
ally
fit
�
freq
uenc
y an
d du
ratio
n of
m
oder
ate
PA (
incl
udin
g ga
rden
ing
and
wal
ks)
�fr
eque
ncy
and
dura
tion
of
vigo
rous
PA
�D
aily
PA
�M
oder
ate
PA fre
quen
cy
�Vi
goro
us P
A fr
eque
ncy
�PA
leve
l: lo
w (
vPA
<1x
/wee
k or
mPA
<
1x/w
eek)
, med
ium
(vP
A 1x
/wee
k or
mPA
1-
4x/w
eek)
, hig
h (v
PA
>2x
/wee
k or
mPA
>
4x/w
eek)
Panc
reat
ic c
ance
r 12
yea
rs
age,
sm
okin
g, m
ultiv
itam
in
Dai
ly P
A N
o 1.
00
Yes
1.08
(0.
81-1
.42)
m
PA f
requ
ency
ra
rely
/nev
er, f
ew
1.00
1
x/w
k, f
ew x
/mon
th
1.06
(0.
71-1
.58)
>
2 x
/wk
1.
14 (
0.79
-1.6
5)
vPA
freq
uenc
y ra
rely
/nev
er, f
ew
1.00
1
x/w
k, f
ew x
/mo
1.02
(0.
63-1
.66)
>
2 x/
wk
0.
93 (
0.55
-1.5
7)
PA le
vel
Low
1.00
M
ediu
m
0.88
(0.
62-1
.24)
H
igh
1.
29 (
0.93
-1.7
7)
Terr
y, e
t al
., (1
999)
Sw
edis
h Tw
in
Regi
stry
(Sw
eden
) N
= 1
1, 6
59
Born
188
6-19
25
Que
stio
nnai
re:
1967
�
PA a
mou
nt:
(no
quan
tific
atio
n)
Endo
met
rial c
ance
r 25
yea
rs
age,
wei
ght,
par
ity
PA
Har
dly
any
1.00
Li
ght
0.
5 (0
.4-0
.8)
Regu
lar
0.6
(0.2
-1.7
) H
ard
0.
1 (0
.04-
0.6)
p
tren
d=<
0.01
198
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Thun
e &
Lu
nd
(199
7)
Nor
way
N
=28
,274
20
-49
year
s of
age
be
twee
n 19
72-
1978
Que
stio
nnai
re:
1972
-197
8 �
PA d
urin
g re
crea
tiona
l hou
rs
�PA
dur
ing
wor
king
hou
rs
�Le
isur
e PA
: se
dent
ary
(e.g
., re
adin
g, T
V), m
oder
ate
(wal
king
/cyc
ling
<4
hour
s/w
eek)
, reg
ular
ex
erci
se t
rain
ing
(>4
hour
s/w
eek)
�
Occ
upat
iona
l PA
�
Leis
ure
+ O
ccup
atio
nal P
A
Lung
can
cer
13-1
9 ye
ars
age
Occ
upat
iona
l PA
Sede
ntar
y 1.
00
Wal
king
0.8
1 (0
.37-
1.76
) Li
ftin
g
0.79
(0.
30-2
.12)
p
tren
d=0.
03
Leis
ure
PA
Sede
ntar
y 1.
00
Mod
erat
e 0.
91 (
0.48
-1.7
1)
Regu
lar
0.
99 (
0.35
-2.7
8)
p tr
end=
0.88
O
ccup
atio
nal P
A +
LTP
A Se
dent
ary
1.00
An
y PA
0.
87 (
0.21
-3.6
2)
Tr
ipat
hi e
t al
., (2
002)
Io
wa
Wom
en's
H
ealth
Stu
dy
(USA
) N
=37
,459
55
-69
year
s of
age
in
198
6
Que
stio
nnai
re:
1986
�
freq
uenc
y an
d du
ratio
n of
m
oder
ate
PA (
incl
udin
g ga
rden
ing
and
wal
ks)
�fr
eque
ncy
and
dura
tion
of
vigo
rous
PA
�Re
gula
r PA
�
PA le
vel:
low
(vP
A <
1x/w
eek
or m
PA
<1x
/wee
k), m
ediu
m (
vPA
1x/w
eek
or m
PA 1
-4x
/wee
k), h
igh
(vPA
>
2x/w
eek
or m
PA
>4x
/wee
k)
Blad
der
carc
inom
a 13
yea
rs
Age,
sm
okin
g, d
iabe
tes,
BM
I,
alco
hol,
mar
ital s
tatu
s, o
ccup
atio
n
Reg
ular
PA
No
1.00
Ye
s 0.
59 (
0.40
-0.8
9)
p <
0.0
5 PA
leve
l Lo
w
1.
00
Med
ium
0.6
2 (0
.38-
1.00
) H
igh
0.
73 (
0.46
-1.1
7)
Reg
ular
PA
N
o 1.
00
Yes
0.66
(0.
43-1
.01)
p
< 0
.05
199
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
van
Dijk
, et
al.,
(2
004)
Net
herla
nds
Coho
rt s
tudy
on
Die
t an
d Ca
ncer
(N
ethe
rland
s)
62,5
73
5-69
yea
rs in
198
6
Que
stio
nnai
re:
1986
�
PA in
pre
viou
s ye
ar
Non
occ
upat
iona
l PA
incl
udin
g le
isur
e PA
, sho
ppin
g, d
og
wal
king
, gar
deni
ng, s
port
s,
exer
cise
, cyc
ling/
wal
king
, act
ive
com
mut
ing
(min
utes
/day
)
Ren
al c
ell c
arci
nom
a Av
erag
e 9.
3 ye
ars
follo
w u
p ag
e, s
mok
ing,
ene
rgy
inta
ke, B
MI
PA m
inut
es/d
ay
<30
1.00
30
-60
1.
13 (
0.59
-2.1
5)
60-9
0
1.43
(0.
73-2
.79)
>
90
1.
13 (
0.56
-2.2
9)
p tr
end=
0.55
N
ote:
BM
I: b
ody
mas
s in
dex,
hrs
: ho
urs,
kca
l: ki
loca
lorie
s, m
PA:
mod
erat
e PA
, PA:
ph
ysic
al a
ctiv
ity, v
PA:
vigo
rous
PA,
wk:
wee
k
200
AP
PEN
DIX
G
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Men
tal H
ealt
h.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Brow
n et
al
., (2
005)
Au
stra
lian
Long
itudi
nal S
tudy
on
Wom
en's
H
ealth
(Au
stra
lia)
N=
9207
45
–50
year
s of
age
in
199
6
Que
stio
nnai
re:
1996
, 199
8,
2001
�19
96:
Fre
quen
cy/w
eek
vigo
rous
exe
rcis
e an
d le
ss
vigo
rous
exe
rcis
e
�19
98, 2
001:
fre
quen
cy a
nd
dura
tion
of w
alki
ng,
mod
erat
e PA
, vig
orou
s PA
in
last
wee
k �
Prev
ious
PA
(199
6+19
98)
(sco
re b
ased
on
ener
gy
expe
nditu
re M
ETS)
: ve
ry
low
(<
440)
; lo
w (
440–
1000
); m
oder
ate
(100
0-<
1760
); h
igh
(>17
60)
�H
abitu
al P
A (1
996+
1998
+20
01)
(bas
ed
on e
nerg
y ex
pend
iture
M
ETS)
: v
ery
low
(<
680)
; lo
w (
680–
<16
00);
mod
erat
e (1
600-
<29
60);
hig
h (>
2960
) �
For
wom
en d
oing
ver
y lo
w
(no
or o
ne P
A se
ssio
n/w
k) in
19
96 c
hang
e PA
ove
r 5
year
s (b
ased
on
ener
gy
Dep
ress
ive
sym
ptom
s Po
or m
enta
l hea
lth
Appr
ox 5
yea
rs
coun
try
of b
irth;
edu
catio
n,
mar
ital s
tatu
s, o
ccup
atio
n,
area
of
resi
denc
e, s
mok
ing
stat
us, B
MI,
men
opau
se
stat
us, b
asel
ine
depr
essi
on,
chro
nic
heal
th c
ondi
tions
Dep
ress
ive
sym
ptom
s m
ean
scor
e by
pre
viou
s PA
<
440
6.
4 (6
.2-6
.6)
440-
1000
6.
0 (5
.8-6
.2)
1000
-176
0 5.
8 (5
.6-6
.0)
>17
60
5.
6 (5
.4-5
.8)
Dep
ress
ive
sym
ptom
s m
ean
scor
e by
hab
itual
PA
<
680
6.
7 (6
.5-7
.0)
680-
<16
00
6.0
(5.8
-6.2
) 16
00-<
2960
5.
8 (5
.6-6
.0)
>29
60
5.
4 (5
.3-5
.6)
Men
tal h
ealth
sco
re m
ean
by p
revi
ous
PA
<44
0
72.5
(71
.8-7
3.8)
44
0-10
00
74.5
(73
.9-7
5.2)
10
00-1
760
75.5
(74
.8-7
6.2)
>
1760
75.9
(75
.3-7
6.5)
M
enta
l hea
lth s
core
mea
n sc
ore
by h
abitu
al P
A
<68
0
71.7
(70
.9-7
2.4)
68
0-<
1600
74
.3 (
73.6
-74.
9)
1600
-<29
60
75.2
(74
.5-7
5.8)
>
2960
76.7
(76
.0-7
7.4)
201
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
expe
nditu
re):
ver
y lo
w t
o <
240
MET
.min
s/w
eek;
ver
y lo
w t
o 24
0 <
600
MET
.min
s/w
eek;
ver
y lo
w t
o >
600
MET
.min
s
Dep
ress
ive
sym
ptom
s by
cha
nge
in P
A Ve
ry lo
w-
<24
0
1.00
Ve
ry lo
w –
(24
0-<
600)
0.
88 (
0.67
–1.1
4)
Very
low
– >
600
0.78
(0.
61–1
.01)
M
enta
l Hea
lth s
core
by
chan
ge in
PA
Very
low
- <
240
1.00
Ve
ry lo
w –
(24
0- <
600)
0.7
6 (0
.56–
1.02
) Ve
ry lo
w -
>60
0 0.
64 (
0.47
–0.8
5)
Gut
hrie
et
al.,
(199
7)
Mel
bour
ne
Wom
en's
Mid
life
Hea
lth P
roje
ct
(Aus
tral
ia)
N=
292
45–5
5 ye
ars
of a
ge
in 1
991
(mea
n 48
.9)
Que
stio
nnai
re:
1991
�Fr
eque
ncy
and
dura
tion
of
part
icip
atio
n in
eac
h of
35
activ
ities
(in
clud
ing
gard
enin
g an
d w
alki
ng)
in
last
yea
r �
PA c
hang
e ov
er 3
yea
rs
(kca
l/wk)
Wel
l-bei
ng
3 ye
ars
Base
line
varia
bles
incl
udin
g he
alth
, str
ess,
BM
I, H
DL-
C,
LDL-
C
Chan
ge in
PA
posi
tivel
y as
soci
ated
with
cha
nge
in
wel
lbei
ng (
ß=0.
0000
68, S
E=0.
0000
38, p
=0.
08)
Heb
ert
et
al.,
(200
0)
Cana
dian
Stu
dy o
f H
ealth
and
Agi
ng
(Can
ada)
N
=57
47
> 6
5 ye
ars
in 1
990
Que
stio
nnai
re:
1990
-199
1 �
Part
icip
atio
n in
reg
ular
PA:
ye
s/no
(un
quan
tifie
d)
Vasc
ular
dem
entia
5
year
s Ag
e an
d re
gion
Regu
lar
exer
cise
N
o 1.
00
Yes
0.46
(0.
25–0
.82)
.
202
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Kritz
-Si
lver
stei
n et
al.,
(2
001)
The
Ranc
ho
Bern
ardo
Stu
dy
(USA
) N
=54
0 58
–89
year
s of
age
in
198
4-19
87
Inte
rvie
w:
198
4-19
8
�Pa
rtic
ipat
ion
in r
egul
ar
stre
nuou
s ex
erci
se o
r ha
rd
phys
ical
labo
ur
�Pa
rtic
ipat
ion
in s
tren
uous
ex
erci
se o
r ha
rd p
hysi
cal
labo
ur
�Ex
erci
se o
r la
bour
3x/
wk
�Re
gula
r st
renu
ous
exer
cise
st
atus
bas
elin
e an
d fo
llow
up
�Ex
erci
se 3
x/w
k st
atus
ba
selin
e an
d fo
llow
up
Dep
ress
ive
sym
ptom
s 8
year
s Ag
e, B
MI,
sm
okin
g, a
lcoh
ol
cons
umpt
ion,
est
roge
n re
plac
emen
t th
erap
y, s
ocia
l su
ppor
t
Dep
ress
ion
scor
e by
reg
ular
str
enuo
us e
xerc
ise
stat
us
No
5.
4 Ye
s
4.9
F=2.
07 n
s D
epre
ssio
n sc
ore
by 3
x/w
k ex
erci
se s
tatu
s N
o
5.6
Yes
5.
2 F=
0.90
ns
Chan
ge in
dep
ress
ion
scor
e by
reg
ular
str
enuo
us
exer
cise
sta
tus
No
-0
.71
Yes
-0
.91
F=0.
33 n
s Ch
ange
in d
epre
ssio
n sc
ore
by 3
x/w
k ex
erci
se
stat
us
No
-0
.68
Yes
-0
.02
F=0.
06 n
s
203
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Mea
n de
pres
sion
sco
re b
y re
gula
r st
renu
ous
exer
cise
sta
tus
base
line
and
follo
w u
p ye
s/ye
s
4.55
no
/yes
4.45
ye
s/no
4.90
no
/no
5.
72
p <
0.08
M
ean
depr
essi
on s
core
by
regu
lar
stre
nuou
s ex
erci
se s
tatu
s ba
selin
e an
d fo
llow
up
yes/
yes
5.
26
no/y
es
5.
55
yes/
no
5.
61
no/n
o
5.85
p=
ns
Laur
in e
t al
., (2
001)
Ca
nadi
an S
tudy
of
Hea
lth a
nd A
ging
(C
anad
a)
N=
3391
>
65
year
s of
age
in
199
0
Que
stio
nnai
re:
1991
-199
2 �
Freq
uenc
y (>
3x/w
k, w
kly,
<
wkl
y) a
nd in
tens
ity (
low
, m
oder
ate,
hig
h) o
f ex
erci
se
Cogn
itive
impa
irmen
t Al
zhei
mer
's d
isea
se
Dem
entia
any
typ
e Co
gniti
ve lo
ss
5 ye
ars
cogn
itive
impa
irmen
t (n
ot d
emen
tia)
none
1.
00
<3x
/wk
0.69
(0.
41–1
.16)
>
3x/w
k, w
alk
0.
55 (
0.36
–0.8
2)
>3
x/w
k, >
wal
k
0.47
(0.
25–0
.90)
p
tren
d=0.
003.
204
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�Co
mpo
site
PA
scor
e re
flect
ing
freq
uenc
y an
d in
tens
ity:
high
PA
(>3
x/w
k at
inte
nsity
>w
alki
ng);
m
oder
ate
PA (
> 3
x/w
k in
tens
ity=
wal
king
); lo
w P
A (<
3 x/
wk)
; no
PA*
Age,
edu
catio
n, fam
ily h
isto
ry
of d
emen
tia, r
egul
ar s
mok
ing,
re
gula
r al
coho
l con
sum
ptio
n,
nons
terio
sal a
nti
infla
mm
ator
y dr
ugs,
act
iviti
es
of d
aily
livi
ng, i
nstr
umen
tal
activ
ities
of
daily
livi
ng,
chro
nic
dise
ase
Alzh
eim
er's
dis
ease
no
ne
1.00
<
3x/w
k
0.
70 (
0.33
–1.4
9)
>3x
/wk,
wal
k
0.87
(0.
51–1
.48)
>
3 x/
wk,
>w
alk
0.
27 (
0.08
–0.9
0)
p tr
end=
0.05
D
emen
tia
none
1.
00
<3x
/wk
0.63
(0.
32–1
.25)
>
3x/w
k, w
alk
0.
67 (
0.55
–1.3
9)
>3
x/w
k, >
wal
k
0.55
(0.
25–1
.21)
p
tren
d=0.
18
Cogn
itive
loss
no
ne
1.00
<
3x/w
k
1.
06 (
0.78
– 1.
45)
>3x
/wk,
wal
k
0.92
(0.
72–
1.17
) >
3 x/
wk,
>w
alk
0.
58 (
0.40
–0.8
2)
p tr
end=
0.01
205
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Lee
&
Russ
ell
(200
3)
Aust
ralia
n Lo
ngitu
dina
l Stu
dy
on W
omen
's
Hea
lth (
Aust
ralia
) N
=64
72
70–7
5 ye
ars
of a
ge
in 1
996
Que
stio
nnai
re 1
996
�Fr
eque
ncy
of v
igor
ous
and
less
vig
orou
s ex
erci
se
Que
stio
nnai
re 1
999
�Ti
me
spen
t in
vPA
, mPA
and
w
alki
ng
�PA
tra
nsiti
on o
ver
3 ye
ars:
se
dent
ary,
ces
satio
n,
adop
tion,
mai
nten
ance
Men
tal h
ealth
Vi
talit
y So
cial
fun
ctio
ning
Em
otio
nal r
ole
func
tioni
ng
4 ye
ars
base
line
PA, S
F-36
, mar
ital
stat
us, B
MI,
rec
ent
life
even
ts
Mea
n ch
ange
in m
enta
l hea
lth
Sede
ntar
y
0.26
Ce
ssat
ion
0.
14
Adop
tion
0.
73
Mai
nten
ance
0.44
p=
0.45
5 M
ean
chan
ge in
vita
lity
Sede
ntar
y
-5.2
3 Ce
ssat
ion
-7
.21*
Ad
optio
n
-1.7
0*
Mai
nten
ance
-1.7
1*
p <
0.00
1
* m
ean
sign
ifica
ntly
diff
eren
t fr
om n
one/
very
low
PA
cat
egor
y M
ean
chan
ge in
soc
ial f
unct
ioni
ng
Sede
ntar
y
-5.1
9 Ce
ssat
ion
-8
.51*
Ad
optio
n
1.25
* M
aint
enan
ce
0.
87*
p <
0.00
1 *
mea
n si
gnifi
cant
ly d
iffer
ent
from
non
e/ve
ry lo
w
PA c
ateg
ory
206
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Mea
n ch
ange
in e
mot
iona
l rol
e fu
nctio
ning
Se
dent
ary
-5
.81
Cess
atio
n
-3.5
1 Ad
optio
n
-1.3
0*
Mai
nten
ance
0.37
* p
<0.
001
* m
ean
sign
ifica
ntly
diff
eren
t fr
om n
one/
very
low
PA
cat
egor
y M
ean
chan
ge in
tot
al m
enta
l hea
lth s
core
Se
dent
ary
-0
.12
Cess
atio
n
-0.5
6 Ad
optio
n
1.38
* M
aint
enan
ce
0.
71
p=0.
002
* m
ean
sign
ifica
ntly
diff
eren
t fr
om n
one/
very
low
PA
cat
egor
y
Pign
atti
et
al.,
(200
2)
(Bre
scia
, Ita
ly)
N=
282
70–7
5 ye
ars
of a
ge
Que
stio
nnai
re
�(n
o in
form
atio
n)
�PA
leve
l: hi
gh (
wal
king
>
2km
/day
); lo
w (
wal
king
<
2 km
/day
)
Cogn
itive
dec
line
Cogn
itive
fun
ctio
ning
12
yea
rs
Base
line
cogn
itive
fun
ctio
ning
Cogn
itive
dec
line
high
PA
17
%
low
PA
40
%
p=0.
02
207
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Cogn
itive
fun
ctio
ning
sco
re a
t ba
selin
e, f
ollo
w u
p hi
gh P
A
9.7
+ 0
.5 t
o 8.
9 +
1.0
; p=
0.00
4 lo
w P
A
9.3
+ 0
.8 t
o 7.
9 +
2.1
; p
<0.
001
Cogn
itive
dec
line
high
PA
1.
00
low
PA
3.
7 (1
.2–1
1.1)
Suut
ama
&
Ruop
pila
(1
998)
Ever
gree
n Pr
ojec
t (F
inla
nd)
N=
84-1
10 b
orn
1914
Ag
ed 7
5 ye
ars
in
1989
N
=37
-61
born
19
10
aged
80
year
s in
19
89
Inte
rvie
w:
198
9 �
phys
ical
dem
and
of le
isur
e tim
e PA
: m
ostly
sitt
ing;
lig
ht P
A; m
PA <
3hrs
/wk;
m
PA >
4hrs
/wk;
exe
rcis
e >
3 hr
s/w
eek;
com
petit
ive
spor
ts s
ever
al x
/wk
�O
bjec
tivel
y as
sess
ed t
ime
to
wal
k 10
met
res
Cogn
itive
sco
re
Rea
ctio
n tim
e 5
year
s
Amon
g co
hort
bor
n 19
14
�Co
rrel
atio
n be
twee
n ba
selin
e PA
and
fol
low
up
cog
nitiv
e sc
ore:
0.0
7 ns
�Co
rrel
atio
n be
twee
n ba
selin
e PA
and
fol
low
up
rea
ctio
n tim
e: -
0.02
ns
�Co
rrel
atio
n be
twee
n ba
selin
e w
alki
ng s
peed
an
d fo
llow
up
cogn
itive
sco
re:
-0.9
ns
�Co
rrel
atio
n be
twee
n ba
selin
e w
alki
ng s
peed
an
d fo
llow
up
reac
tion
time:
0.3
5, p
<0.
001
Amon
g c
ohor
t bo
rn 1
914
�Co
rrel
atio
n be
twee
n ba
selin
e PA
and
fol
low
up
cog
nitiv
e sc
ore:
0.1
7 ns
�Co
rrel
atio
n be
twee
n ba
selin
e PA
and
fol
low
up
rea
ctio
n tim
e: -
0.13
ns
208
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�Co
rrel
atio
n be
twee
n ba
selin
e w
alki
ng s
peed
an
d fo
llow
up
cogn
itive
sco
re:
-1.4
ns
�Co
rrel
atio
n be
twee
n ba
selin
e w
alki
ng s
peed
an
d fo
llow
up
reac
tion
time:
0.2
6 ns
Weu
ve e
t al
., (2
004)
N
urse
s' H
ealth
St
udy
(USA
) N
=18
,766
70
–81
year
s of
age
Que
stio
nnai
re:
1995
-200
1 �
Aver
age
time/
wk
runn
ing,
jo
ggin
g, w
alki
ng, r
acqu
et
spor
ts, s
wim
min
g, c
yclin
g,
aero
bics
, exe
rcis
e m
achi
nes,
vP
A (e
g ga
rden
ing)
, low
PA
(eg
aero
bics
) �
Usu
al w
alki
ng p
ace:
>
30m
in/m
ile;
21-3
0 m
in/m
ile;
16-2
0min
/mile
; <
15 m
in/m
ile
�To
tal P
A en
ergy
exp
endi
ture
(M
ET.h
ours
/wee
k)
quin
tiles
:.
Cogn
itive
sta
tus
Cate
gory
flu
ency
W
orki
ng m
emor
y an
d at
tent
ion
Verb
al m
emor
y G
loba
l cog
nitiv
e fu
nctio
ning
M
ean
1.8
year
s Ag
e, e
duca
tion,
hus
band
's
educ
atio
n, a
lcoh
ol u
se,
smok
ing
stat
us, a
spiri
n us
e,
vita
min
E u
se, b
alan
ce
prob
lem
s, h
ealth
lim
itatio
ns
for
wal
king
, ost
eoar
thrit
is,
emph
ysem
a or
chr
onic
br
onch
itis,
fat
igue
, poo
r m
enta
l hea
lth, a
ntid
epre
ssan
t us
e, m
oder
ate-
seve
re b
odily
pa
in
Mea
n di
ffer
ence
in c
hang
e in
cog
nitiv
e st
atus
<
5.2
1.
00
5.2–
10.0
0.
17 (
0.05
-0.3
0)
10.1
–16.
2 0.
17 (
0.04
-0.2
9)
16.3
–26.
0 0.
28 (
0.15
-0.4
1)
>26
.0
0.
34 (
0.21
-0.4
7)
p <
0.00
1 M
ean
diff
eren
ce in
cha
nge
in c
ateg
ory
fluen
cy
<5.
2
1.00
5.
2–10
.0
0.04
(-0
.16-
0.25
) 10
.1–1
6.2
0.07
(-0
.13-
0.29
) 16
.3–2
6.0
0.18
(-0
.03-
0.39
) >
26.0
0.19
(-0
.02-
0.40
) p=
0.05
209
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Mea
n di
ffer
ence
in c
hang
e in
wor
king
mem
ory
and
atte
ntio
n <
5.2
1.
00
5.2–
10.0
0.
12 (
0.01
-0.2
3)
10.1
–16.
2 0.
13 (
0.02
-0.2
4)
16.3
–26.
0 0.
20 (
0.08
-0.3
1)
>26
.0
0.
25 (
0.13
-0.3
6)
p <
0.00
1 M
ean
diff
eren
ce in
cha
nge
in v
erba
l mem
ory
<5.
2
1.00
5.
2–10
.0
0.04
(0.
00-0
.07)
10
.1–1
6.2
0.01
(-0
.02-
0.04
) 16
.3–2
6.0
0.04
(0.
01-0
.08)
>
26.0
0.07
(0.
04-0
.11)
p
<0.
001
Mea
n di
ffer
ence
in c
hang
e in
glo
bal c
ogni
tive
func
tioni
ng
<5.
2
1.00
5.
2–10
.0
0.03
(0.
00-0
.05)
10
.1–1
6.2
0.01
(-0
.01-
0.04
) 16
.3–2
6.0
0.04
(0.
01-0
.07)
>
26.0
0.06
(0.
03-0
.08)
p
<0.
001
210
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Yaff
e et
al
., (2
001)
St
udy
of
Ost
eopo
rotic
Fr
actu
res
(USA
) N
=59
25
> 6
5 ye
ars
<70
yea
rs o
f ag
e=33
40
>70
yea
rs o
f ag
e=25
85
Inte
rvie
w:
198
6-19
88
�N
umbe
r of
blo
cks
wal
ked/
w
k (b
lock
~ 1
60m
)
�Fr
eque
ncy
and
dura
tion/
wk
of p
artic
ipat
ion
in 3
3 ac
tiviti
es
�N
umbe
r of
blo
cks
wal
ked
/ w
eek
(blo
ck ~
160
m)
quar
tiles
: 0
–22
(med
ian=
7);
23–4
9 (m
edia
n=28
); 5
0-11
2 (m
edia
n=77
); 1
13–6
72
(med
ian=
175)
.
�To
tal P
A qu
artil
es
(kca
l/wee
k):
0–6
15
(med
ian
336)
; 61
6–13
23
(med
ian=
936)
; 13
24–2
414
(med
ian=
1773
); 2
415-
1753
1 (m
edia
n=34
69)
Cogn
itive
dec
line
6-8
year
s Ag
e, e
duca
tion,
dep
ress
ion,
st
roke
, dia
bete
s,
hype
rten
sion
, myo
card
ial
infa
rctio
n, s
mok
ing,
est
roge
n us
e, f
unct
iona
l lim
itatio
n
Bloc
ks w
alke
d/w
k 0–
22
1.
00
23–4
9
0.87
(0.
72–1
.05)
50
-112
0.
63 (
0.52
–0.7
7)
113–
672
0.66
(0.
54–0
.82)
To
tal P
A (k
cal/w
k)
0–61
5
1.00
61
6–13
23
0.90
(0.
74–1
.09)
13
24–2
414
0.78
(0.
64–0
.96)
24
15-1
7531
0.
74 (
0.60
–0.9
0)
Aged
< 7
0 ye
ars,
blo
cks
wal
ked/
wk
0–
22
1.
00
23–4
9
0.67
(0.
51–0
.87)
50
-112
0.
61 (
0.47
–0.7
9)
113–
672
0.55
(0.
42–0
.71)
Ag
ed <
70
year
s, t
otal
PA
(kca
l/wk)
0–
615
1.
00
616–
1323
0.
78 (
0.60
–1.0
2)
1324
–241
4 0.
70 (
0.54
–0.9
2)
2415
-175
31
0.65
(0.
50–0
.86)
211
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Aged
> 7
0 ye
ars,
blo
cks
wal
ked/
wk
0–22
1.00
23
–49
1.
07 (
0.83
–1.3
5)
50-1
12
0.77
(0.
60–0
.98)
11
3–67
2 0.
78 (
0.60
–1.0
1)
Aged
> 7
0 ye
ars,
tot
al P
A (k
cal/w
k)
0–61
5
1.00
61
6–13
23
0.91
(0.
72–1
.15)
13
24–2
414
0.77
(0.
60–0
.98)
24
15-1
7531
0.
74 (
0.57
–0.9
5)
Not
e: B
MI:
bod
y m
ass
inde
x; k
m:
kilo
met
re;
kcal
: k
iloca
lorie
s; m
PA=
mod
erat
e ac
tivity
; ns
: no
t si
gnifi
cant
; vP
A=vi
goro
us a
ctiv
ity;
wk:
wee
k
212
AP
PEN
DIX
H
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Mus
culo
skel
etal
Hea
lth.
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Cheu
ng e
t al
., (2
000)
Ae
robi
cs C
entr
e Lo
ngitu
dina
l St
udy
(USA
) N
=40
73
20–8
7 ye
ars
of
age
Que
stio
nnai
re w
ith in
terv
iew
:
1970
-199
0
�Re
gula
r ex
erci
se p
atte
rn:
di
stan
ce w
alke
d an
d/or
jo
gged
/wee
k; o
ther
typ
es o
f PA
�
Regu
lar
PA (
mile
s/w
eek)
: hi
gh (
wal
k or
jog
>20
m
iles/
wee
k), m
oder
ate
(wal
k or
jog
10-2
0 m
iles/
wee
k), l
ow (
wal
k or
jo
g <
10 m
iles/
wee
k), o
ther
re
gula
r PA
, sed
enta
ry
Ost
eoar
thrit
is o
f th
e kn
ee
and/
or h
ip
Up
to 2
5 ye
ars
Age,
BM
I, s
mok
ing,
eth
anol
, ca
ffei
ne
Regu
lar
PA (
all a
ges)
Se
dent
ary
1.
0 >
20 m
iles/
wk
1.
0 (0
.4-2
.3)
10-2
0 m
iles/
wk
1.
1 (0
.9-1
.3)
<10
mile
s/w
k
1.7
(0.4
-1.1
) O
ther
reg
ular
PA
0.9
(0.6
-1.3
) Reg
ular
PA
(tho
se a
ged
<50
yea
rs)
Sede
ntar
y
1.0
>20
mile
s/w
k
1.5
(0.4
-5.1
) 10
-20
mile
s/w
k
1.2
(0.9
-1.5
) <
10 m
iles/
wk
1.
8 (0
.4-1
.6)
Oth
er r
egul
ar P
A 1.
1 (0
.6-2
.0)
Reg
ular
PA
(tho
se a
ged
>50
yea
rs)
Sede
ntar
y
1.0
>20
mile
s/w
k
1.4
(0.4
-4.6
) 10
-20
mile
s/w
k
1.2
(0.9
-1.5
) <
10 m
iles/
wk
1.
6 (0
.3-1
.2)
Oth
er r
egul
ar P
A 0.
7 (0
.4-1
.3)
213
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Fels
on, e
t al
., (1
997)
Fr
amin
gham
St
udy
(USA
) N
=38
1 Av
erag
e ag
e 70
.5
year
s
Que
stio
nnai
re:
1954
-195
7,
1971
-197
3, 1
985-
1993
�
Usu
al a
ctiv
ity d
urin
g ea
ch
hour
of
a ty
pica
l day
�
PA q
uart
iles
base
d on
Fr
amin
gham
inde
x (k
cals
)
Ost
eoar
thrit
is o
f th
e kn
ee
7-10
yea
rs
age,
BM
I, w
eigh
t ch
ange
, sm
okin
g, k
nee
inju
ry,
chon
droc
alci
nosi
s, h
and
oste
oart
hriti
s
PA le
vel
Sede
ntar
y 1.
0 H
ighe
st
3.1
(1.1
-8.6
)
Har
t et
al.,
(1
999)
Ch
ingf
ord
Stud
y (U
K)
N=
830
Aver
age
54.1
ye
ars
Inte
rvie
w:
1988
-89
�(n
o in
form
atio
n pr
ovid
ed)
�W
alki
ng
�Jo
b PA
�
Spor
t
(no
info
rmat
ion
prov
ided
)
Ost
eoar
thrit
is o
f th
e kn
ee
4 ye
ars
hyst
erec
tom
y, h
orm
one
repl
acem
ent
ther
apy,
sm
okin
g, k
nee
pain
, soc
ial
clas
s
Wal
king
0.
60 (
0.22
-1.7
1)
Job
PA
1.48
(0.
34-5
.64)
Sp
ort
1.
23 (
0.54
-2.8
1)
Hoo
tman
, et
al.,
(200
3)
Aero
bics
Cen
tre
Long
itudi
nal
Stud
y (U
SA)
N=
976
Que
stio
nnai
re:
1986
�
Inte
nsity
, dur
atio
n an
d fr
eque
ncy
of e
ach
of
wal
king
, run
ning
/jog
ging
, bi
cycl
ing,
sw
imm
ing,
rac
ket
spor
ts, o
ther
str
enuo
us
spor
ts, s
tret
chin
g ex
erci
ses,
Ost
eoar
thrit
is o
f kn
ee a
nd/o
r hi
p Av
erag
e 12
.8 y
ears
PA +
join
t st
ress
sco
re
Sede
ntar
y 1.
00
Low
1.25
(0.
61-2
.57)
M
oder
ate
1.16
(0.
64-2
.12)
H
igh
1.
07 (
0.47
-2.4
2)
214
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
>40
yea
rs o
f ag
e 25
% a
ged
<50
ye
ars
calis
then
ics,
wei
ght
trai
ning
du
ring
prev
ious
12
mon
ths
�X
by jo
int
stre
ss o
f PA
�
Join
t st
ress
sco
re b
ased
on
(MET
.min
/wee
k) X
join
t st
ress
wei
ght
valu
e: l
ow
(low
est
25%
), m
id (
mid
50
%),
hig
h (h
ighe
st 2
5%)
age,
pre
viou
s kn
ee/h
ip in
jury
, pr
evio
us k
nee/
hip
surg
ery;
BM
I, c
omor
bid
cond
ition
, sm
okin
g st
atus
Seav
ey, e
t al
., (2
003)
Al
amed
a Co
unty
St
udy
(USA
) N
=11
48
Aged
>16
yea
rs
Que
stio
nnai
re:
197
4 �
Freq
uenc
y of
par
ticip
atio
n in
ac
tive
spor
ts, s
wim
min
g or
ta
king
long
wal
ks, h
untin
g or
fis
hing
, gar
deni
ng, d
oing
ph
ysic
al e
xerc
ises
�
LTPA
inde
x (q
uint
iles)
. Su
mm
ed f
requ
ency
sco
re
acro
ss P
A ite
ms
whe
re o
ften
(4
poi
nts)
, som
etim
es (
2 po
ints
), n
ever
(0
poin
ts).
Ra
nge
0-16
.
Arth
ritis
20
yea
rs
age,
rac
e, B
MI,
dep
ress
ion
LTPA
inde
x Lo
wes
t qu
artil
e
1.00
2nd
qua
rtile
0.80
(0.
56-1
.14)
3rd
qua
rtile
0.79
(0.
53-1
.20)
H
ighe
st q
uart
ile
0.76
(0.
50-1
.16)
Not
es.
BMI:
bod
y m
ass
inde
x, k
cal:
kilo
calo
ries,
LTP
A=le
isur
e tim
e PA
; M
ET:
met
abol
ic e
quiv
alen
t, P
A: ph
ysic
al a
ctiv
ity
215
AP
PEN
DIX
I
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Inju
ry.
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Albr
and
et
al.,
(200
3)
OFE
LY (
Fran
ce)
N=
672
Post
men
opau
sal:
aver
age
age
59.1
ye
ars
Inte
rvie
w:
1992
-199
3 �
Rece
nt P
A at
hom
e �
Rece
nt P
A at
occ
upat
ion
�Re
cent
PA
at h
ome
activ
ities
�
Past
spo
rts
activ
ity
�PA
sco
re (
rang
e 0-
27;
med
ian=
14):
sed
enta
ry –
no
/ligh
t PA
(<
14);
mod
erat
e or
hig
h PA
(>
14)
�
Ost
eopo
rotic
fra
ctur
es
5 ye
ars
frac
ture
his
tory
, grip
str
engt
h,
age,
mat
erna
l his
tory
fra
gilit
y fr
actu
re, p
ast
falls
, bon
e m
ass
dens
ity h
ip
PA s
core
M
oder
ate/
Hig
h
1.00
Se
dent
ary-
no/li
ght
PA
2.08
(1.
17-3
.69)
p=
0.01
Chap
urla
t et
al.,
(2
003)
Stud
y of
O
steo
poro
tic
Frac
ture
s (U
SA)
632
(with
pre
viou
s fr
actu
re)
>65
yea
rs o
f ag
e
Que
stio
nnai
re:
1986
-198
8 �
wal
king
Seco
nd h
ip fr
actu
re
2 ye
ars
bone
mas
s de
nsity
, dep
th
perc
eptio
n, w
eigh
t ga
in s
ince
25
year
s, o
estr
ogen
use
Regu
lar
wal
king
for
exe
rcis
e N
o 1.
00
Yes
0.7
(0.3
– 1
.6)
p=0.
35
216
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Fesk
anic
h et
al.,
(2
002)
Nur
ses
Hea
lth
Stud
y (U
SA)
N=
61,2
00
40–7
7 ye
ars
of a
ge
Que
stio
nnai
re:
1980
�
hour
s/w
eek
mPA
+ v
PA t
o sw
eat
Que
stio
nnai
re:
1986
, 198
8,
1992
, 199
4 �
aver
age
time/
wee
k in
w
alki
ng, j
oggi
ng, r
unni
ng,
bicy
clin
g, r
acqu
et s
port
s,
swim
min
g, a
erob
ics
�w
alki
ng p
ace:
eas
y (<
2mph
); a
vera
ge (
2-2.
9 m
ph);
bris
k (3
-3.9
mph
);
very
bris
k (>
4 m
ph)
Que
stio
nnai
re:
1996
�
as a
bove
�
othe
r vP
A e
g ga
rden
ing
�ot
her
low
inte
nsity
PA
eg
yoga
Q
uest
ionn
aire
: 19
88, 1
990,
19
92
�tim
e si
ttin
g an
d st
andi
ng
(hom
e, w
ork,
oth
er)
hip
frac
ture
12
yea
rs
BMI,
age
, sm
okin
g, p
ost
men
opau
sal h
orm
one
use,
ca
lciu
m, v
itam
in D
, pro
tein
, vi
tam
in K
, alc
ohol
, caf
fein
e
Tota
l PA
(MET
.hou
rs/w
k)
<3
1.
00
3-8.
9
0.79
(0.
60–1
.03)
9-
14.9
0.67
(0.
49–0
.92)
15
-23.
9
0.53
(0.
37–0
.74)
>
24
0.
45 (
0.32
–0.6
3)
p tr
end
<0.
001
Wal
king
tim
e (h
ours
/wk)
<
1
1.00
1
0.
79 (
0.55
–1.1
4)
2-3
0.
78 (
0.53
–1.1
4)
>4
0.
59 (
0.37
–0.9
4)
p tr
end=
0.02
W
alki
ng p
ace
(mph
) <
2
1.00
2-
2.9
0.51
(0.
37–0
.71)
>
3
0.35
(0.
22–0
.55)
217
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�PA
ene
rgy
expe
nditu
re
(MET
.hou
rs/w
eek)
�W
alki
ng t
ime
(hou
rs/w
eek)
�W
alki
ng p
ace
(mile
s/ho
ur)
�Ch
ange
in P
A am
ong
thos
e se
dent
ary
at b
asel
ine
(hou
rs/w
eek)
�Ch
ange
in P
A am
ong
thos
e do
ing
>4
hour
s/w
eek
at
base
line
(hou
rs/w
eek)
PA c
hang
e am
ong
thos
e se
dent
ary
at b
asel
ine
(hou
rs/w
k)
<1
1.
00
1
0.86
(0.
52–1
.43)
2-
3
0.79
(0.
45–1
.38)
>
4
0.53
(0.
27–1
.04)
p
tren
d=0.
07
PA c
hang
e RR
am
ong
thos
e m
ost
activ
e at
ba
selin
e (h
ours
/wk)
>
4
1.00
2-
3
1.73
(1.
02-2
.95)
1
1.
47 (
0.80
-2.7
1)
<1
2.
08 (
1.20
–3.6
1)
p tr
end=
0.00
4 Si
ttin
g (h
ours
/wk)
<
10
1.
00
10-2
4
0.96
(0.
65-1
.43)
25
-39
1.
02 (
0.67
-1.5
5)
40-5
4
0.96
(0.
62-1
.47)
>
55
1.
29 (
0.85
-1.9
6)
p tr
end=
0.16
218
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Stan
ding
(ho
urs/
wk)
<
10
1.
00
10-2
4
0.77
(0.
55-1
.07)
25
-39
0.
77 (
0.55
-1.0
9)
40-5
4
0.66
(0.
45-0
.97)
>
55
0.
54 (
0.35
-0.8
4)
p tr
end=
0.01
Gre
gg e
t al
., (1
998)
St
udy
of
Ost
eopo
rotic
Fr
actu
res
(USA
) N
=97
04
>65
yea
rs o
f ag
e
Que
stio
nnai
re:
�
Freq
uenc
y an
d du
ratio
n of
pa
rtic
ipat
ion
in e
ach
of 3
3 ac
tiviti
es
�N
umbe
r ci
ty b
lock
s (o
r eq
uiva
lent
) w
alke
d/da
y �
Num
ber
fligh
ts s
tairs
cl
imbe
d/da
y �
Tota
l PA
ener
gy e
xpen
ditu
re
quin
tiles
for
spo
rt +
LTP
A +
bl
ocks
wal
ked
+ s
tairs
cl
imbe
d (k
cal/w
eek)
�
Spor
t or
LTP
A in
tens
ity
(hig
hest
leve
l)
Hip
fra
ctur
e w
rist
or v
erte
bral
fra
ctur
es
Aver
age
7.6
year
s ag
e, w
eigh
t, s
mok
ing,
es
trog
en r
epla
cem
ent
ther
apy,
die
tary
cal
cium
, fal
ls,
alco
hol u
se, f
unct
iona
l di
ffic
ulty
hip
frac
ture
by
tota
l PA
(kca
l/wk)
<
340
1.
00
341–
737
0.77
(0.
58–1
.02)
73
8–12
89
0.78
(0.
59–1
.04)
12
90–2
201
0.64
(0.
47–0
.88)
>
2201
0.64
(0.
45–0
.89)
p
tren
d=0.
003
hip
frac
ture
by
LTPA
inte
nsity
no
ne
1.
00
low
0.76
(0.
61–0
.95)
m
od-v
ig
0.58
(0.
43–0
.79)
p
tren
d=0.
0004
219
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�In
tens
ity o
f LT
PA
�H
eavy
cho
res
time
(hou
rs/w
eek)
�
Sitt
ing
time
hip
frac
ture
by
PA t
ime
and
inte
nsity
(ho
urs/
wk)
no
ne
1.
00
low
0.76
(0.
61–0
.95)
m
od-v
ig
0.58
(0.
43-0
.79)
p
tren
d=0.
0004
hi
p fr
actu
re b
y he
avy
chor
es (
hour
s/w
k)
<5
1.
00
5-9
0.
93 (
0.72
–1.2
0)
>9
0.
78 (
0.62
–0.9
9)
p tr
end=
0.14
hi
p fr
actu
re b
y si
ttin
g (h
ours
/day
) <
6
1.00
6-
8
0.98
(0.
77-1
.25)
>
8
1.37
(1.
08-1
.76)
p
tren
d=0.
01
220
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
wris
t fr
actu
re b
y to
tal P
A (k
cal/w
k)
<34
0
1.00
34
1–73
7 0.
92 (
0.70
–1.2
2)
738–
1289
0.
95 (
0.71
–1.2
5)
1290
–220
1 0.
90 (
0.67
–1.2
0)
>22
01
0.
85 (
0.63
–1.1
5)
p tr
end
>0.
2 w
rist
frac
ture
by
LTPA
inte
nsity
no
ne
1.
00
low
1.10
(0.
87–1
.40)
m
od-v
ig
1.13
(0.
86–1
.49)
p
tren
d >
0.2
wris
t fr
actu
re b
y he
avy
chor
es (
hour
s/w
k)
<5
1.
00
5-9
0.
91 (
0.74
–1.1
2)
>9
0.
86 (
0.71
–1.0
5)
p tr
end=
0.09
221
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
wris
t fr
actu
re b
y si
ttin
g (h
ours
/day
) <
6
1.00
6-
8
0.91
(0.
74-1
.12)
>
8
1.09
(0.
87-1
.36)
p
tren
d >
0.2
vert
ebra
l fra
ctur
e by
tot
al P
A (k
cal/w
k)
<34
0
1.00
34
1–73
7 0.
76 (
0.54
– 1.
05)
738–
1289
0.
63 (
0.44
–0.8
9)
1290
–220
1 0.
99 (
0.72
–1.3
8)
>22
01
0.
84 (
0.59
–1.1
9)
p tr
end
>0.
2 ve
rteb
ral f
ract
ure
by L
TPA
inte
nsity
no
ne
1.
00
low
0.99
(0.
76–1
.29)
m
od-v
ig
0.67
(0.
49–0
.94)
p
tren
d=0.
01
222
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
vert
ebra
l fra
ctur
e by
hea
vy c
hore
s(ho
urs/
wk)
<
5
1.00
5-
9
1.04
(0.
79–1
.39)
>
9
1.09
(0.
85–1
.39)
p
tren
d >
0.2
vert
ebra
l fra
ctur
e by
sitt
ing
(hou
rs/d
ay)
<6
1.
00
6-8
1.
22 (
0.95
-1.5
6)
>8
1.
09 (
0.82
-1.4
4)
p tr
end
>0.
2
Hun
drup
et
al.,
(2
005)
Dan
ish
Nur
se
Coho
rt S
tudy
on
the
prev
entio
n of
os
teop
oros
is a
nd
athe
rosc
lero
sis
(Den
mar
k)
N=
14,0
15
>50
yea
rs o
f ag
e M
edia
n 59
yea
rs
Que
stio
nnai
re:
1993
�
Sede
ntar
y or
doi
ng li
ght-
heav
y PA
>4
hour
s/w
k �
PA/w
eek
Hip
fra
ctur
e 6
year
s ho
rmon
e re
plac
emen
t th
erap
y, B
MI,
hea
lth, a
ctiv
ity
rest
rictio
ns, s
mok
ing
stat
us,
prev
ious
wris
t fr
actu
re, f
amily
hi
stor
y os
teop
oros
is, a
lcoh
ol
inta
ke, a
ge m
enar
che
PA /
wk
Ligh
t-he
avy
>4
1.
00
Sede
ntar
y
1.88
(1.
30–2
.70)
p
< 0
.001
223
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Iver
s et
al
., (2
002)
Bl
ue M
ount
ains
Ey
e St
udy
(Aus
tral
ia)
N=
2072
>
49 y
ears
of
age
Que
stio
nnai
re:
199
2-19
93
�Pa
rtic
ipat
ion
in r
ecen
t vP
A �
vPA
in la
st t
wo
wee
ks
wris
t fr
actu
res
5 ye
ars
age,
hor
mon
e re
plac
emen
t th
erap
y
vPA
yes
1.
00
no
0.
4 (0
.2–0
.9)
Kush
i et
al.,
(199
7)
Iow
a W
omen
's
Hea
lth S
tudy
(U
SA)
N=
32,7
63
55–6
9 ye
ars
of a
ge
in 1
986
Que
stio
nnai
re:
1986
�
any
regu
lar
daily
leis
ure
time
PA (
not
occu
patio
nal o
r do
mes
tic)
to k
eep
phys
ical
ly
fit
�fr
eque
ncy
and
dura
tion
of
mod
erat
e PA
(in
clud
ing
gard
enin
g an
d w
alks
) �
freq
uenc
y an
d du
ratio
n of
vi
goro
us P
A �
regu
lar
PA
�m
PA f
requ
ency
(x/
wee
k)
�vP
A fr
eque
ncy
(x/w
eek)
Inju
ry m
orta
lity
7 ye
ars
age
at b
asel
ine,
age
at
men
arch
e, a
ge a
t m
enop
ause
, age
at
first
live
bi
rth,
par
ity, a
lcoh
ol in
take
, to
tal e
nerg
y in
take
, cig
aret
te
smok
ing,
est
roge
n us
e, B
MI
at b
asel
ine,
BM
I at
age
18,
w
aist
to
hip
ratio
, edu
catio
n,
mar
ital s
tatu
s
Reg
ular
PA
No
1.
00
Yes
0.
45
mPA
(x/
wk)
ra
rely
/nev
er
1.
00
few
x/m
onth
–1x/
wk
0.94
(0.
31–2
.82)
2-
4 x/
wk
0.
99 (
0.33
–2.9
7)
>4
x/w
k
0.37
(0.
07–1
.91)
p
tren
d=0.
26
224
Ref
eren
ce
Stud
y N
umbe
r &
Age
of
Wom
en
Phys
ical
Act
ivity
Mea
sure
men
t O
utco
me
Follo
w-u
p Pe
riod
Adju
stm
ents
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�PA
leve
l: lo
w (
vPA
<1
x/w
eek
OR
mPA
<1
x/w
eek)
; m
ediu
m (
vPA
1x/w
eek
OR
mPA
1-
4x/w
eek)
; hi
gh (
vPA
>2x
/wee
k O
R m
PA
>4x
/wee
k)
vPA
(x/w
k)
rare
ly/n
ever
1.00
fe
w x
/mon
th–1
x/w
k 0.
00
2-4
x/w
k
0.59
(0.
08–4
.44)
>
4 x/
wk
0.
00
p tr
end=
0.99
PA
leve
l Lo
w
1.
00
Med
ium
0.
97 (
0.38
–2.4
8)
Hig
h
0.45
(0.
13–1
.63)
p
tren
d=0.
22
N
ote:
BM
I: b
ody
mas
s in
dex;
LTP
A: le
isur
e tim
e ph
ysic
al a
ctiv
ity;
mPA
=m
oder
ate
PA;
mph
: m
iles
per
hour
; vP
A=vi
goro
us P
A; w
k: w
eek
225
AP
PEN
DIX
J
Popu
lati
on B
ased
Stu
dies
of
the
Ass
ocia
tion
Bet
wee
n Ph
ysic
al A
ctiv
ity
and
Rep
rodu
ctiv
e H
ealt
h.
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Gut
hrie
et
al.,
(200
5)
Mel
bour
ne
Wom
en's
Mid
life
Hea
lth P
roje
ct
(Aus
tral
ia)
N=
381
45–5
5 ye
ars
Inte
rvie
w:
1991
�
Freq
uenc
y of
exe
rcis
e fo
r fit
ness
or
recr
eatio
n �
PA f
requ
ency
: ne
ver;
<1/
m
onth
; fe
w /
mon
th;
1 /w
eek;
2-3
/w
eek;
4-6
/w
eek;
dai
ly.
Men
opau
sal h
ot flu
shes
9
year
s Ag
e, B
MI,
neg
ativ
e m
ood,
es
trad
iol l
evel
s, s
mok
ing,
em
ploy
men
t, m
enop
ause
st
atus
, alc
ohol
inta
ke,
educ
atio
n, n
umbe
r da
ily
hass
les
Exer
cise
dai
ly
OR:
0.9
4 (
betw
een
grou
ps)
p=0.
01
OR:
-0.
12 (
with
in p
erso
n)
p=0.
02
Hat
ch e
t al
., (1
998)
Pe
nnsy
lvan
ia a
nd
New
Yor
k Pr
enat
al
Patie
nts
(USA
) N
=71
7 Av
erag
e ag
e 27
ye
ars
Inte
rvie
w:
13 w
eeks
of ge
stat
ion
�Ti
me
spen
t in
leis
ure
time
PA
�Le
isur
e PA
ene
rgy
expe
nditu
re d
urin
g pr
egna
ncy
(kca
l/wee
k):
no
exer
cise
; lo
w–m
oder
ate
(<10
00);
hea
vy (
>10
00)
Ges
tatio
nal l
engt
h Ap
prox
23
wee
ks
smok
ing,
pre
viou
s m
isca
rria
ge o
r pr
e te
rm
deliv
ery,
dat
ing
by u
ltra
soun
d, m
ater
nal a
ge, p
arity
, pr
e-pr
egna
ncy
wei
ght,
firs
t tr
imes
ter
blee
ding
, stu
dy s
ite,
per
capi
ta in
com
e
Red
uced
ges
tatio
nal d
urat
ion
lo
w-m
oder
ate
PA
1.00
no
exe
rcis
e
1.11
(0.
88–1
.39)
D
eliv
ery
at w
eek
32 (
pret
erm
) N
o ex
erci
se
1.
00
Hea
vy, n
ot c
ondi
tione
d 0.
53 (
0.07
-4.1
7)
Hea
vy, c
ondi
tione
d 0.
01 (
0.00
-0.5
2)
226
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�PA
con
ditio
ning
dur
ing
preg
nanc
y: n
o ex
erci
se;
heav
y no
t co
nditi
oned
(>
1000
kca
l/wee
k AN
D
ener
gy e
xpen
ditu
re in
tr
imes
ter
prio
r to
ex
amin
atio
n <
1000
kc
al/w
eek)
; he
avy
cond
ition
ed (
>10
00
kcal
/wee
k AN
D e
nerg
y ex
pend
iture
in t
rimes
ter
prio
r to
exa
min
atio
n >
1000
kc
al/w
eek)
Del
iver
y at
wee
k 34
(pr
eter
m)
No
exer
cise
1.00
H
eavy
, not
con
ditio
ned
0.62
(0.
13-2
.97)
H
eavy
, con
ditio
ned
0.04
(0.
00-0
.65)
D
eliv
ery
at w
eek
36 (
pret
erm
) N
o ex
erci
se
1.
00
Hea
vy, n
ot c
ondi
tione
d 0.
72 (
0.24
-2.1
5)
Hea
vy, c
ondi
tione
d 0.
11 (
0.02
-0.8
1)
Del
iver
y at
wee
k 40
(te
rm)
No
exer
cise
1.00
H
eavy
, not
con
ditio
ned
0.96
(0.
59-1
.58)
H
eavy
, con
ditio
ned
1.05
(0.
64-1
.73)
D
eliv
ery
at w
eek
42 (
post
date
) N
o ex
erci
se
1.
00
Hea
vy, n
ot c
ondi
tione
d 1.
12 (
0.54
-2.3
2)
Hea
vy, c
ondi
tione
d 3.
21 (
1.22
-8.4
8)
Del
iver
y at
wee
k 43
(po
stte
rm)
No
exer
cise
1.00
H
eavy
, not
con
ditio
ned
1.20
(0.
47-3
.07)
H
eavy
, con
ditio
ned
5.62
(1.
41-2
2.47
)
227
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Mis
ra e
t al
., (1
998)
Uni
vers
ity o
f M
aryl
and
Med
ical
Sy
stem
s St
udy
(USA
) N
=1,
188
Age
not
give
n
Inte
rvie
w (
1st, 2
nd t
rimes
ter)
�O
ccup
atio
nal P
A: li
ftin
g he
avy
obje
cts,
st
andi
ng/m
ovin
g
�PA
of
daily
life
: st
airs
cl
imbe
d (t
imes
/day
),
purp
osiv
e w
alki
ng
(day
s/w
eek)
, lift
ing
heav
y ob
ject
s
�Le
isur
e-tim
e ex
erci
se
(num
ber
of d
ays)
�
Stai
rs c
limbe
d (t
imes
/day
)
�Pu
rpos
ive
wal
king
(d
ays/
wee
k)
�Li
ftin
g he
avy
obje
cts
at
hom
e
�Le
isur
e-tim
e ex
erci
se
(num
ber
of d
ays)
�W
atch
ing
tele
visi
on
(hou
rs/w
eek)
Pre-
term
del
iver
y w
ithou
t co
mpl
icat
ions
1st
pre
nata
l vis
it –
birt
h ra
ce, m
ater
nal a
ge, u
se o
f ill
icit
drug
s, p
rena
tal c
are,
m
othe
r's h
eigh
t, s
mok
ing,
in
sura
nce,
prio
r fe
tal l
osse
s,
prio
r lo
w b
irth
wei
gh d
eliv
ery,
bl
eedi
ng, h
yper
tens
ion,
an
tepa
rtum
hos
pita
lizat
ion,
fe
brile
/ant
ibio
tic
adm
inis
trat
ion
Stai
r cl
imbi
ng (
times
/day
) <
10
1.00
>
10
2.04
(1.
23–3
.36)
Pu
rpos
ive
wal
king
(da
ys/w
k)
<4
1.00
>
4 2.
16 (
1.31
–3.5
7)
Lift
ing
heav
y ob
ject
s at
hom
e no
1.
00
yes
1.59
(0.
85–2
.96)
Le
isur
e tim
e ex
erci
se (
num
ber
of d
ays)
>
60
1.00
>
60
0.55
(0.
26–1
.14)
W
atch
ing
tele
visi
on (
hour
s/w
k)
<15
1.84
(0.
96-3
.52)
15
-28
1.
00
29-4
2
1.01
(0.
49-2
.09)
>
42
2.
73 (
1.40
-5.3
3)
228
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
Ster
nfel
d et
al.,
(2
002)
Sem
icon
duct
or
Indu
stry
Coh
ort
Repr
oduc
tive
Out
com
es S
tudy
N
=36
7 18
–44
year
s in
19
89
Inte
rvie
w:
198
9 �
Tim
es/m
onth
and
min
utes
sp
ent
in e
ach
of 6
3 re
crea
tiona
l act
iviti
es in
pr
evio
us m
onth
�
Leis
ure
time
PA e
nerg
y ex
pend
iture
(M
ET.in
s/w
eek)
�Le
isur
e tim
e vP
A (M
ET.m
ins/
wee
k)
�M
inut
es p
er d
ay o
f vP
A
Men
stru
al c
ycle
leng
th
Med
ian
of fiv
e m
enst
rual
cy
cles
ag
e, e
thni
city
, edu
catio
n,
mar
ital s
tatu
s, p
arity
, sm
okin
g st
atus
, alc
ohol
co
nsum
ptio
n
Incr
ease
in 3
0 M
ET.m
ins/
wk
tota
l PA
insi
gnifi
cant
ly a
ssoc
iate
d w
ith 0
.001
-day
incr
ease
in
mea
n cy
cle
leng
th (
SE=
0.00
7), p
=0.
86
Incr
ease
in 3
0 M
ET.m
ins/
wk
vPA
insi
gnifi
cant
ly
asso
ciat
ed w
ith 0
.009
-day
incr
ease
in m
ean
cycl
e le
ngth
(SE
=0.
009)
, p=
0.29
As
soci
atio
n be
twee
n cy
cle
spec
ific
men
stru
al c
ycle
le
ngth
and
per
cyc
le m
ean
min
utes
of
daily
vPA
in
conc
urre
nt c
ycle
ß=
0.02
45 (
SE=
0.01
06)
p=0.
02
Mea
n m
ins
vPA
for
prev
ious
cyc
le p
ositi
vely
and
di
sgni
fican
tly r
elat
ed t
o cy
cle
leng
th
ß=-0
.035
(SE
=0.
015)
M
ichi
gan
Bone
H
ealth
Stu
dy
N=
328
24–4
8 ye
ars
in
1992
Que
stio
nnai
re:
1992
�
Num
ber
times
and
dur
atio
n of
ran
ge o
f le
isur
e tim
e PA
�
Num
ber
times
and
dur
atio
n of
occ
upat
iona
l PA
�N
umbe
r tim
es a
nd d
urat
ion
of h
ouse
hold
act
iviti
es
�D
urin
g Ju
ly-J
anau
ry
Men
stru
al c
ycle
leng
th
Med
ian
11 m
enst
rual
cyc
les
age,
eth
nici
ty, e
duca
tion,
m
arita
l sta
tus,
par
ity,
smok
ing
stat
us, a
lcoh
ol
cons
umpt
ion
Asso
ciat
ion
betw
een
vPA
(per
30
MET
.min
s/w
k)
and
men
stru
al c
ycle
leng
th ß
=0.
075
(SE=
0.02
8),
p=0.
008
Asso
ciat
ion
betw
een
vPA
and
blee
d le
ngth
ß=
0.00
4 (S
E=0.
002)
p=
0.03
1
229
Ref
eren
ce
Num
ber
& A
ge o
f W
omen
Ph
ysic
al A
ctiv
ity M
easu
rem
ent
Out
com
e Fo
llow
-up
Perio
d Ad
just
men
ts
Sum
mar
y of
Res
ults
(9
5% c
onfid
ence
inte
rval
)
�To
tal P
A (M
ET.m
ins/
wk)
�Le
isur
e tim
e PA
(M
ET.m
ins/
wk)
�vP
A (M
ET.m
in/w
k)
Posi
tive
asso
ciat
ion
of b
leed
leng
th w
ith t
otal
PA
ß=0.
001
(SE=
0.00
03)
p=0.
023
Posi
tive
asso
ciat
ion
of b
leed
leng
th w
ith le
isur
e tim
e PA
ß=
0.00
4 (S
E=0.
001)
p=
0.00
3
Not
e: B
MI:
bod
y m
ass
inde
x; k
cal:
kilo
calo
ries;
min
s: m
inut
es;
mPA
=m
oder
ate
PA;
OR o
dds
ratio
; vP
A=vi
goro
us P
A; w
k: w
eek
www.alswh.org.au