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A drive for the health benefits of walking
EDITORIALS
A Drive for the Health Benefits of Walking Howard D. Sesso, ScD, MPH
P
hysical activity reduces the risk of coronary heart disease, stroke, diabetes, hypertension, colon cancer, and other chronic diseases (1). Recent statements from the US Surgeon General (2), the National Institutes of Health Consensus Development Panel on Physical Activity and Cardiovascular Health (3), and the Centers for Disease Control and Prevention and the American College of Sports Medicine (4) recommend that adults should engage in 30 or more minutes of at least moderate-intensity physical activity on most, and preferably all, days of the week to prevent coronary heart disease and other chronic diseases. However, more than 60% of US adults are not regularly active (2). The decision to expand the present recommendations to include moderate activities, in addition to vigorous activities, was based on the premise that moderate physical activities are easily attainable and can be accomplished in either several small daily increments or a single longer increment. Two recent trials (5,6) found that moderate-intensity physical activity might have similar benefits on coronary risk factors as structured, more vigorous activities. These studies found an association between lifestyle activities— expressed by walking, climbing stairs, and other short bouts of moderate-intensity physical activity—and long-term improvements in peak oxygen consumption, physical fitness, body composition, and serum lipid levels. In this issue of the Journal, Parkkari et al (7) report the potential benefits of moderate-intensity physical activity in the form of walking during golf. Walking is an extremely practical, convenient, and safe form of sustained dynamic aerobic exercise that can be done in occupational, home, and recreational settings (8). For a 20-week intervention study, Parkkari et al (7) assigned 110 initially sedentary men aged 45 to 65 years to play golf or to continue their usual pattern of inactivity. Extensive measurements of body composition, physical fitness and function, and fasting blood samples were performed at baseline and the end of the intervention period. The authors used physical activity diaries to monitor ex-
Am J Med. 2000;109:160 –161. From the Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts and the Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts. Correspondence and requests for reprints should be addressed to Howard D. Sesso, ScD, MPH, Brigham and Women’s Hospital, 900 Commonwealth Avenue East, Boston Massachusetts 02215–1204. 160
䉷2000 by Excerpta Medica, Inc. All rights reserved.
ercise patterns in the treatment groups, revealing no major differences in physical activity between the groups other than playing golf. More extensive data were collected on the golfers to gauge the quantity and intensity of energy expended during a typical round of golf. The authors concluded that those who walked during golf exhibited modest improvements in various measures of body composition, physical fitness and function, and serum high-density lipoprotein (HDL) cholesterol levels compared with those men asked to continue their sedentary lifestyles. The key, then, is to understand how these findings add to the growing literature on the potential benefits of moderate-intensity physical activity, such as walking, on health. First, the short-term benefits noted by Parkkari et al (7) need to be shown to result in long-term health improvements that reduce the risk of various chronic diseases. High compliance rates are vital to confer such longterm benefits. Walking during golf is a form of physical activity that can be enjoyed by people of different ages. The high compliance rates reported in this study may reflect a genuine enjoyment for walking during golf outings; alternatively, they may have become obsessed with lowering their handicaps. Regardless of their motivations to walk and golf, the initiation of a “Health Enhancing Golf Program” to keep these golfers physically active during nonplaying months can provide invaluable follow-up on the postintervention maintenance of physical activity. In a 10-year postintervention follow-up of women previously enrolled in a walking intervention trial, those in the walking intervention group had greater long-term exercise compliance and corresponding health benefits (9). Similar high rates of long-term compliance have been reported in other trials (5,6). Despite the modest health benefits derived from walking during golf in this study by Parkkari et al (7), weather, cost, and time requirements may preclude sedentary people from considering golf as a means of becoming active. Colder climates are less conducive to golf as a year-round activity. Also, golf can be a costly means of exercise after accounting for equipment and greens fees, thus making affordability and broader access more problematic. The men in this study played an average of 2.5 rounds of golf per week, or about 10 hours per week, which is considerably greater than the amount of activity presently recommended by the US Surgeon General. This amount of activity may be difficult to attain by many adults given their occupational or familial responsibilities, which may have 0002-9343/00/$–see front matter PII S0002-9343(00)00491-5
Health Benefits of Walking/Sesso
limited their ability to be physically active in the first place. A recognition of the social and psychological barriers that may dissuade people against longer bouts of vigorous- or moderate-intensity physical activity motivated the US Surgeon General’s recommendation to allow for the accumulation of shorter bouts of activities (2). This was seen as an alternative to mandating a single, longer bout of exercise. Parkkari et al (7) remind us that longer bouts of moderate-intensity exercise in the form of walking during golf may be feasible for some sedentary individuals. What remains unclear is whether longer bouts of moderate-intensity physical activity lead to greater physiologic improvements than the accumulation of several shorter bouts. Alternatively, the use of a golf cart may still allow for a sufficient amount of walking for people to experience positive health effects. This intermediate approach remains an improvement over staying sedentary with the goal of increasing the likelihood for sedentary people to become, and remain, more active. Exactly how walking fits into the equation for the appropriate quantity and intensity of physical activity for the prevention of various diseases remains an active area of investigation (10). A handful of studies have examined the association between walking and the risk of coronary heart disease (11,12). Parkkari et al (7) provide additional evidence for mechanisms by which walking may reduce the risk of chronic diseases, including body composition, physical fitness and function, and HDL cholesterol levels. The finding that walking during golf may lower blood pressure only among those with the highest initial blood pressure is intriguing but may only reflect regression to the mean. More research is needed to identify the biological pathways by which walking may improve short- and long-term health. Despite our knowledge of the health benefits associated with physical activity, clinicians, public health professionals, and legislators must continue to focus their efforts at getting sedentary people to become more active. One recent study highlighted the importance of environmental and policy approaches to promote physical activity through the development of walking trails in the community (13). The work of Parkkari and colleagues (7) add further credibility that walking in any form, whether during golf or integrated into a pattern of lifestyle physical
activity, provides a reasonable, safe way by which to become physically active with modest health benefits (5). For sedentary people, any increase in their physical activity level appears beneficial, whether recommended in the form of walking during golf, or another activity that someone is motivated not just to start, but to sustain as part of their usual, active lifestyle.
REFERENCES 1. Blair SN, Horton E, Leon AS, et al. Physical activity, nutrition, and chronic disease. Med Sci Sports Exerc. 1996;28:335–349. 2. US Department of Health, and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 3. NIH Consensus Development Panel on Physical Activity, and Cardiovascular Health. Physical activity and cardiovascular health. JAMA. 1996;276:241–246. 4. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995; 273:402– 407. 5. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness. JAMA. 1999;281: 327–334. 6. Andersen RE, Wadden TA, Bartlett SJ, Zemel B, Verde TJ, Franckowiak SC. Effects of lifestyle activity vs structured aerobic exercise in obese women: a randomized trial. JAMA. 1999;281:335–340. 7. Parkkari J, Natri A, Kannus P, et al. A controlled trial of the health benefits of regular walking on a golf course. Am J Med. 2000;109: 102–108. 8. Morris JN, Hardman AE. Walking to health. Sports Med. 1997;23: 306 –332. 9. Pereira MA, Kriska AM, Day RD, Cauley JA, LaPorte RE, Kuller LH. A randomized walking trial in postmenopausal women: effects on physical activity and health 10 years later. Arch Intern Med. 1998; 158:1695–1701. 10. Siegel PZ, Brackbill RM, Heath GW. The epidemiology of walking for exercise: implications for promoting activity among sedentary groups. Am J Public Health. 1995;85:706 –710. 11. Sesso HD, Paffenbarger RS Jr, Lee I-M. Physical activity and coronary heart disease risk in men: the Harvard Alumni Health Study. Circulation 2000:in press. 12. Manson JE, Hu FB, Rich-Edwards JW, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. NEJM. 1999;341:650 – 658. 13. Brownson RC, Housemann RA, Brown DR, et al. Promoting physical activity in rural communities. Walking trail access, use, and effects. Am J Prev Med. 2000;18:235–241.
August 1, 2000
THE AMERICAN JOURNAL OF MEDICINE威
Volume 109 161
A Drive for the Health Benefits of Walking Howard D. Sesso, ScD, MPH
P
hysical activity reduces the risk of coronary heart disease, stroke, diabetes, hypertension, colon cancer, and other chronic diseases (1). Recent statements from the US Surgeon General (2), the National Institutes of Health Consensus Development Panel on Physical Activity and Cardiovascular Health (3), and the Centers for Disease Control and Prevention and the American College of Sports Medicine (4) recommend that adults should engage in 30 or more minutes of at least moderate-intensity physical activity on most, and preferably all, days of the week to prevent coronary heart disease and other chronic diseases. However, more than 60% of US adults are not regularly active (2). The decision to expand the present recommendations to include moderate activities, in addition to vigorous activities, was based on the premise that moderate physical activities are easily attainable and can be accomplished in either several small daily increments or a single longer increment. Two recent trials (5,6) found that moderate-intensity physical activity might have similar benefits on coronary risk factors as structured, more vigorous activities. These studies found an association between lifestyle activities— expressed by walking, climbing stairs, and other short bouts of moderate-intensity physical activity—and long-term improvements in peak oxygen consumption, physical fitness, body composition, and serum lipid levels. In this issue of the Journal, Parkkari et al (7) report the potential benefits of moderate-intensity physical activity in the form of walking during golf. Walking is an extremely practical, convenient, and safe form of sustained dynamic aerobic exercise that can be done in occupational, home, and recreational settings (8). For a 20-week intervention study, Parkkari et al (7) assigned 110 initially sedentary men aged 45 to 65 years to play golf or to continue their usual pattern of inactivity. Extensive measurements of body composition, physical fitness and function, and fasting blood samples were performed at baseline and the end of the intervention period. The authors used physical activity diaries to monitor ex-
Am J Med. 2000;109:160 –161. From the Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts and the Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts. Correspondence and requests for reprints should be addressed to Howard D. Sesso, ScD, MPH, Brigham and Women’s Hospital, 900 Commonwealth Avenue East, Boston Massachusetts 02215–1204. 160
䉷2000 by Excerpta Medica, Inc. All rights reserved.
ercise patterns in the treatment groups, revealing no major differences in physical activity between the groups other than playing golf. More extensive data were collected on the golfers to gauge the quantity and intensity of energy expended during a typical round of golf. The authors concluded that those who walked during golf exhibited modest improvements in various measures of body composition, physical fitness and function, and serum high-density lipoprotein (HDL) cholesterol levels compared with those men asked to continue their sedentary lifestyles. The key, then, is to understand how these findings add to the growing literature on the potential benefits of moderate-intensity physical activity, such as walking, on health. First, the short-term benefits noted by Parkkari et al (7) need to be shown to result in long-term health improvements that reduce the risk of various chronic diseases. High compliance rates are vital to confer such longterm benefits. Walking during golf is a form of physical activity that can be enjoyed by people of different ages. The high compliance rates reported in this study may reflect a genuine enjoyment for walking during golf outings; alternatively, they may have become obsessed with lowering their handicaps. Regardless of their motivations to walk and golf, the initiation of a “Health Enhancing Golf Program” to keep these golfers physically active during nonplaying months can provide invaluable follow-up on the postintervention maintenance of physical activity. In a 10-year postintervention follow-up of women previously enrolled in a walking intervention trial, those in the walking intervention group had greater long-term exercise compliance and corresponding health benefits (9). Similar high rates of long-term compliance have been reported in other trials (5,6). Despite the modest health benefits derived from walking during golf in this study by Parkkari et al (7), weather, cost, and time requirements may preclude sedentary people from considering golf as a means of becoming active. Colder climates are less conducive to golf as a year-round activity. Also, golf can be a costly means of exercise after accounting for equipment and greens fees, thus making affordability and broader access more problematic. The men in this study played an average of 2.5 rounds of golf per week, or about 10 hours per week, which is considerably greater than the amount of activity presently recommended by the US Surgeon General. This amount of activity may be difficult to attain by many adults given their occupational or familial responsibilities, which may have 0002-9343/00/$–see front matter PII S0002-9343(00)00491-5
Health Benefits of Walking/Sesso
limited their ability to be physically active in the first place. A recognition of the social and psychological barriers that may dissuade people against longer bouts of vigorous- or moderate-intensity physical activity motivated the US Surgeon General’s recommendation to allow for the accumulation of shorter bouts of activities (2). This was seen as an alternative to mandating a single, longer bout of exercise. Parkkari et al (7) remind us that longer bouts of moderate-intensity exercise in the form of walking during golf may be feasible for some sedentary individuals. What remains unclear is whether longer bouts of moderate-intensity physical activity lead to greater physiologic improvements than the accumulation of several shorter bouts. Alternatively, the use of a golf cart may still allow for a sufficient amount of walking for people to experience positive health effects. This intermediate approach remains an improvement over staying sedentary with the goal of increasing the likelihood for sedentary people to become, and remain, more active. Exactly how walking fits into the equation for the appropriate quantity and intensity of physical activity for the prevention of various diseases remains an active area of investigation (10). A handful of studies have examined the association between walking and the risk of coronary heart disease (11,12). Parkkari et al (7) provide additional evidence for mechanisms by which walking may reduce the risk of chronic diseases, including body composition, physical fitness and function, and HDL cholesterol levels. The finding that walking during golf may lower blood pressure only among those with the highest initial blood pressure is intriguing but may only reflect regression to the mean. More research is needed to identify the biological pathways by which walking may improve short- and long-term health. Despite our knowledge of the health benefits associated with physical activity, clinicians, public health professionals, and legislators must continue to focus their efforts at getting sedentary people to become more active. One recent study highlighted the importance of environmental and policy approaches to promote physical activity through the development of walking trails in the community (13). The work of Parkkari and colleagues (7) add further credibility that walking in any form, whether during golf or integrated into a pattern of lifestyle physical
activity, provides a reasonable, safe way by which to become physically active with modest health benefits (5). For sedentary people, any increase in their physical activity level appears beneficial, whether recommended in the form of walking during golf, or another activity that someone is motivated not just to start, but to sustain as part of their usual, active lifestyle.
REFERENCES 1. Blair SN, Horton E, Leon AS, et al. Physical activity, nutrition, and chronic disease. Med Sci Sports Exerc. 1996;28:335–349. 2. US Department of Health, and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 3. NIH Consensus Development Panel on Physical Activity, and Cardiovascular Health. Physical activity and cardiovascular health. JAMA. 1996;276:241–246. 4. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995; 273:402– 407. 5. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW, Blair SN. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness. JAMA. 1999;281: 327–334. 6. Andersen RE, Wadden TA, Bartlett SJ, Zemel B, Verde TJ, Franckowiak SC. Effects of lifestyle activity vs structured aerobic exercise in obese women: a randomized trial. JAMA. 1999;281:335–340. 7. Parkkari J, Natri A, Kannus P, et al. A controlled trial of the health benefits of regular walking on a golf course. Am J Med. 2000;109: 102–108. 8. Morris JN, Hardman AE. Walking to health. Sports Med. 1997;23: 306 –332. 9. Pereira MA, Kriska AM, Day RD, Cauley JA, LaPorte RE, Kuller LH. A randomized walking trial in postmenopausal women: effects on physical activity and health 10 years later. Arch Intern Med. 1998; 158:1695–1701. 10. Siegel PZ, Brackbill RM, Heath GW. The epidemiology of walking for exercise: implications for promoting activity among sedentary groups. Am J Public Health. 1995;85:706 –710. 11. Sesso HD, Paffenbarger RS Jr, Lee I-M. Physical activity and coronary heart disease risk in men: the Harvard Alumni Health Study. Circulation 2000:in press. 12. Manson JE, Hu FB, Rich-Edwards JW, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. NEJM. 1999;341:650 – 658. 13. Brownson RC, Housemann RA, Brown DR, et al. Promoting physical activity in rural communities. Walking trail access, use, and effects. Am J Prev Med. 2000;18:235–241.
August 1, 2000
THE AMERICAN JOURNAL OF MEDICINE威
Volume 109 161