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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


The University of Queensland, St Lucia QLD 4072

Tel: 07 3365 6446 Fax: 07 3365 6877

Email: [email protected]

SecondaryContact

Dr Nicola Burton


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.


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).


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).


5


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.


7


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.


9


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.


11


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1 (low) 2 3 4 5 (high)

Physical activity level

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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

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1

1 (low) 2 3 4 5 (high)

Level of walking

Rela

tive

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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


13


0.4

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1

1.1

none easy moderate brisk very fast

Walking pace

Rel

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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.


15


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1.1

1 (low) 2 3 4 5 (high)

Physical activity level

Rel

ativ

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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.


17


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1 (low) 2 3 4 5 (high)

Level of walking

Rel

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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


19


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).


21


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

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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


23


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

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Level of vigorous-intensity physical activity

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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.


25


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


27


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


29


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


31


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


33


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).


35


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


37


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).


39


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).


41


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.


43


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.

How Much Activity for Health Benefits?

45


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.


47


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.


49


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.


51


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.


53


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.

How Active are Australian Women?

55


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.


57


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.


59


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).


61


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).


63


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.


65


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


67


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.


69


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.


71


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).


73


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%


75


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


77


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).


79


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.


81


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.


83


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).


85


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


87


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


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.


91


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.


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(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

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pre-pre pre-peri peri-peri pre/peri-post post-post

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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.


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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)


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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

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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.


99


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).

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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).


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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.


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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.


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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).

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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).


109


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).

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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).

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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


113


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%.


115


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


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.


117


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.


119


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

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APPENDICES

140

AP

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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

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