Updating the Evidence on Physical Activity and Health in Women

Review and Special Articles

Updating the Evidence on Physical Activity and Health in Women Wendy J. Brown, PhD, Nicola W. Burton, PhD, Paul J. Rowan, PhD Objective:

This narrative review updates evidence from the last 10 years on physical activity (PA) and the primary prevention of cardiovascular disease, diabetes, and cancer in women.

Methods:

A literature search was conducted to identify prospective cohort studies published from January 1997 to February 2006.

Results:

There were significant reductions in risk in 12 of 17 studies of cardiovascular outcomes (risk reductions ranging from 28% to 58%), in seven of eight studies of diabetes (14% to 46%), in seven of ten studies of breast cancer (11% to 67%), in two of two studies of endometrial cancer (68% to 90%), and in one of three studies of colorectal cancer (31% to 46%). There was mixed evidence for PA preventing gestational diabetes (three studies) and a range of other cancers (13 studies). Protective benefits for cardiovascular disease and diabetes were reported with as little as 60 minutes of moderate-intensity physical activity per week (240 Metabolic Equivalent (MET) minutes or 4 MET hours), with walking and moderate-intensity physical activity providing risk reductions comparable to those for the equivalent energy expenditure from more vigorous-intensity physical activity.

Conclusions: There is strong evidence of a role for PA in the primary prevention of cardiovascular disease, diabetes, and some cancers in women. There was no evidence of additional health benefits from vigorous-intensity PA, over and above those achieved from walking or moderate-intensity PA. This may be because, in most studies, there was limited reporting of vigorous PA by women. For some health outcomes, the amount of PA required for health benefits in middle-aged and older women might be lower than current national recommendations. (Am J Prev Med 2007;33(5):404 – 411) © 2007 American Journal of Preventive Medicine

Introduction

L

ast year (2006) was the 10-year anniversary of the landmark United States Surgeon General’s Report on Physical Activity and Health.1 Released on the eve of the Centennial Olympic Games in Atlanta GA, it was perhaps ironic that 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 for the health benefits of physical activity, especially in the areas of coronary heart disease, diabetes, hypertension, colon cancer, mental health, musculoskeletal health, and obesity. Although it did include some sections specific to women (e.g., on breast and hormone-dependent cancers), a striking feature of the Surgeon General’s report

From the School of Human Movement Studies, University of Queensland (Brown, Burton), St Lucia, Queensland, Australia; Division of Management, Policy, and Community Health, The University of Texas-Houston School of Public Health (Rowan), Houston, Texas Address correspondence and reprint requests to: Wendy J Brown, PhD, School of Human Movement Studies, University of Queensland, St Lucia, Queensland 4072, Australia. E-mail: [email protected]. edu.au.

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was that most of the evidence was based on studies of men. The early large cohort studies, including Morris’s studies of London Transport workers2 and British civil servants,3 Paffenbarger’s studies of Harvard alumni4 and San Francisco longshoremen,5 Taylor’s study of U.S. railroad industry employees,6 the British Regional Heart Study,7 and the Lipid Research Clinics prevalence survey,8 included only men. Only six of the 51 studies on physical activity and cardiovascular disease, coronary heart disease, and stroke in the Surgeon General’s report1 included women. Even in cancer epidemiology, male participants in studies of prostate cancer outnumbered the female participants in studies of breast cancer by two to one. There are several reasons why it is timely to update the evidence relating physical activity to health in women. There are biological gender differences, for example, in hormones and body fat, which may contribute to gender differences in physiologic responses9 that, in turn, affect the etiology of health problems. Women’s patterns of energy expenditure in paid and unpaid work, commuting, and in leisure time, may be different from those of men.10 There are also now

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many more published studies of physical activity and health in women than at the time the Surgeon General’s report1 was released. The purpose of this narrative review therefore was to update the evidence on physical activity and the primary prevention of three major chronic health problems (cardiovascular disease, diabetes, and cancer) in women and to identify emerging areas for future research. These three health outcomes were selected because of their high burden of disease in women.11 The decision to restrict this review to cohort studies was based on the belief that data obtained from retrospective case– control studies can be biased by limitations in recalling past physical activity (e.g., over 5–20 years). Randomized controlled trials can provide very useful information about disease etiology, but problems with compliance and cost make it difficult to sustain these over periods that are sufficiently long for health outcomes to develop, so their role in primary prevention research is currently somewhat limited.

Methods A literature search was conducted to identify published studies of physical activity and the primary prevention of cardiovascular disease, diabetes, and cancer in women. CINAHL, PRE CINAHL, PSYCHINFO, PSYCHLIT, and MEDLINE electronic databases were utilized with the following search terms: physical activity, exercise, female, women, longitudinal, prospective, cohort, health, diabetes, cancer, cardiovascular, heart, coronary, and mortality. Studies were included if they utilized a prospective cohort design, had physical activity as a primary study variable, were published between January 1997 and February 2006, and were written in English. Studies that included both men and women were included if results were stratified by gender. The titles and abstracts of identified publications were checked for relevance. The reference lists of relevant articles, reviews, and meta-analyses were checked for additional papers. Each study was individually reviewed by the first two authors (WB, NB). A summary of the results of the studies is presented in Appendixes A-1 through A-6, which are available on the journal website (www.ajpm-online.net). Relative risks (RR) are reported as the measure of association, typically with 95% confidence intervals (CI). The results are described in narrative format in the following sections. The term dose– response was used to describe graded effects of the relationship between physical activity and health outcomes.

Results Physical Activity Measurement Several issues related to the measurement of physical activity made summarizing data from different studies challenging. While this paper was not intended as a critique of physical activity measurement, a brief summary of these issues is provided here, as this is relevant to the interpretation of much of the published evidence in this area. November 2007

Measurement of self reported physical activity varied from a single question about perceptions (e.g., how active do you think you are compared with others your age?) to multiple questions about generic domains (e.g., walking, moderate-intensity or vigorous-intensity), or specific types (e.g., blocks walked, stairs climbed, bicycling, specific sports). In order to assess dose–response relationships, physical activity was typically categorized as low, moderate, or high, based on tertiles, quartiles, or quintiles of the distribution of the physical activity measure in each cohort. As this distribution, and the measures themselves, varied across cohorts, this made direct comparisons of study findings challenging. The units used to denote total energy expenditure attributable to physical activity (derived from frequency, intensity, and duration) also varied. Earlier studies tended to use kilojoules or kilocalories, while more recent studies reported metabolic equivalents (METs; multiples of resting energy expenditure), reported as either MET hours or MET minutes per week. Some studies reported only the duration of physical activity, and did not assess energy expenditure at all. For the purposes of this review, the results of those studies that provided an estimate of energy expenditure were highlighted, as this measure provided a better indicator of exposure than, for example, a measure of frequency. Some studies relied on a single measure of physical activity recorded for several years (typically 5–10) before the outcome measure was assessed, and others measured physical activity at multiple time points to examine changing levels during the follow-up period. Strategies for managing repeated measures varied (e.g., averaging, summing, categorizing as changed/unchanged). These cumulative or average measures offered a better indicator of dose than a single recall. Follow-up periods also varied widely (from 2 to 31 years in the studies reported here), and the shorter periods might have been insufficient for some health outcomes to develop. The domains of physical activity assessed varied across the studies. While virtually all the studies focused on leisure-time activities, for some this was limited to sports and recreational exercise, while for others this also included stair climbing, gardening, and domestic chores. Although Canadian researchers have estimated that household chores account for 82% of women’s physical activity,12 it is not known whether these are carried out at an intensity sufficient to elicit health benefits.13 Some studies separated walking from other activity domains, while others combined it with bicycling to commute to and from places, or with moderateintensity physical activity. A limited number of studies assessed occupational physical activity, but only three studies14 –16 used this as an independent study variable, rather than including it in an overall measure of energy expenditure. Measurement of work-related physical acAm J Prev Med 2007;33(5)

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tivity has proven to be especially challenging in women—particularly among those who do not have consistent patterns of physical activity in their paid and unpaid work. Sedentary behaviors such as sitting and watching television were included in some studies. These differences also made the comparison of study results challenging. In the larger cohort studies, researchers were able to adjust for the effects of a range of potential confounders, including risk behaviors such as smoking and alcohol use; diet (fat, fiber, fruit and vegetables); hormone replacement therapy; body composition and size (body mass index [BMI], waist-to-hip ratio); personal and family history of chronic diseases such as diabetes; and biological markers such as cholesterol level and blood pressure. In most studies, the inclusion of these potential confounders attenuated the relationship between physical activity and health outcomes. The multivariate-adjusted relative risk values (i.e., those with the most covariates) were presented. This meant that the estimates of the association between physical activity and health outcomes presented in this review were conservative and did not take into account the additional favorable effects on adiposity and other intermediate-risk factors such as cholesterol and blood pressure.17

Cardiovascular Disease The Surgeon General’s 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.1 The level of risk reduction with regular physical activity was noted to be similar to that of other behavioral risk factors such as not smoking,1 and there were no conclusive data relating physical activity and stroke. Only 2% of participants in the Surgeon General–reviewed studies of CVD were women.1 Seventeen new studies12,17–32 on physical activity and cardiovascular outcomes in women were found: 12 showed significant risk reductions,12, 17, 19, 21, 24 –31 two had equivocal findings,20,23 and three showed no significant relationships.18, 22, 32 (See Appendix A-1 online.) Data from three of the large U.S. women’s cohort studies (the Women’s Health Study,27 the Women’s Health Initiative,17 and the Nurses’ Health Study28) suggested that participation in physical activity with energy expenditure equivalent to as little as 1 to 3 hours a week of moderate-intensity physical activity was associated with a 20%–30% reduction in cardiovascular outcomes. Greater total energy expenditure of physical activity (either through increasing intensity or duration) resulted in further reductions in the RR of cardiovascular disease, with RRs as low as 0.4717 (see Appendix A-1 online). The most marked significant 406

decrease in risk in any study was reported from the Nord–Trondelag Study19 with a substantial risk reduction for women who reported the highest levels of vigorous physical activity (RR⫽0.42, 95% CI⫽0.240.75). Importantly, the Study of Osteoporotic Fractures found that women who became physically active later in life had rates of CVD mortality similar to those of women who were active at baseline, and that recent physical activity was a more significant predictor of longevity than past physical activity.21 The Surgeon General’s report did not find a consistent relationship between physical activity and stroke.1 However, since 1997, data from four studies have provided evidence of an inverse relationship between physical activity and risk of ischemic stroke in women.19,25,29,30 In two of the studies,29,30 however, the physical activity measure was not described in detail. Data from several studies of the association between physical activity and CVD support the notion that the benefits can be realized with brisk walking.17,21,25,27,28 Among women who did not do any other form of physical activity, as little as 1 hour of walking per week was associated with a RR reduction of 18%–50% for several CVD outcomes, including stroke.17,25,28 In these studies, compliance with national guidelines was associated with a further reduction in risk, with an average RR of about 0.62 for ⬎10 MET hours per week of walking (2.5 hours)17,21,25,27,28 (see Appendix A-1 online). These studies also showed that the speed of walking was important. The average RR for CVD outcomes among women who walked slowly (⬍3.2 km/ hour to 4.6 km/hour) was 0.71, while for those who walked faster (⬎4.6 km/hour) the average RR was about 0.5525,27,28 (see Appendix A-1 online).

Type 2 Diabetes The Surgeon General’s report found that regular physical activity lowered the risk of developing non-insulindependent diabetes mellitus (NIDDM).1 In 1996, three large U.S. cohort studies (the male college alumni study,33 the male physicians study,34 and the Nurses’ Health Study35) had already provided good evidence of significant reductions in risk of NIDDM with quite small increments in physical activity. Eight new reports on physical activity and type 2 diabetes in women22,36 – 42 were located (see Appendix A-2 online), with seven indicating significant risk reductions.37– 42 (The term diabetes is used here for type 2 diabetes, as the term NIDDM, as used in the Surgeon General’s report, is not now routinely used.) The three large U.S. women’s cohort studies including the Nurses’ Health Study,39,40 the Women’s Health Initiative,38 and the Women’s Health Study42 all reported significant inverse associations between physical activity and incident diabetes (see Appendix A-2 on-

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line). Interestingly, the most recent report from the Women’s Health Initiative found this relationship only in Caucasian women, and not in African-American, Hispanic, or Asian/Pacific Islander women.38 The researchers hypothesized that the non-Caucasian women did not perform sufficient physical activity to reach a hypothetical threshold for benefit, and confirmed that the African-American and Hispanic (but not the Asian) women were less active. However, when the analysis was restricted to women with similar activity levels, the differences between Caucasian and other women persisted.38 The authors stressed however, that these findings were “provocative,” rather than definitive, and required further research. Another study41 involving a different ethnic group 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 BMI. This smaller study (with approximately 1000 women) was the only cohort study to have used an objective measure of diabetes (oral glucose tolerance test) instead of self-report. Both the Nurses’ Health Study and the Women’s Health Study however had conducted substudies to verify self-report of diabetes using blood samples and physician reports. The Nurses’ Health Study reported that diabetes was confirmed in 98% of their subsample of 62 women,35 and the Women’s Health Study reported that diabetes was confirmed in 91% of their subsample of 473 women.42 In addition to confirming the relationship between total physical activity and lowered risk of diabetes, the Nurses’ Health Study also published several important papers on walking and diabetes. Using data from 8 years of follow-up, the researchers found a significant inverse association between energy expenditure from walking and risk of diabetes, and increased risk reduction with faster pace of walking.40 They concluded that equivalent energy expenditures from moderate- and vigorous-intensity physical activity might confer similar benefits, with each additional hour per day of brisk walking associated with a 34% reduction in diabetes.40 A second study, with data from 6 years of follow-up, reported that sedentary behaviors, especially watching television, were associated with significantly increased risk of diabetes independent of exercise levels.39 Sedentary occupations (i.e., long hours of sitting or standing at work) were significantly associated with BMI, 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 a significantly reduced risk of diabetes.39

Gestational Diabetes Although the Surgeon General’s report1 reviewed the evidence on physical activity and diabetes, it did not November 2007

include any studies of gestational diabetes (GDM). However, as GDM affects 5–9 % of pregnancies,43 there is increasing interest in the role of physical activity in its prevention. This is particularly salient because women who have GDM are six times more likely to develop type 2 diabetes later in life than women without GDM, and up to 50% of women who have had GDM develop type 2 diabetes.44 Three studies of gestational diabetes were identified and these provided mixed results45– 47 (see Appendix A-3 online). The Nurses’ Health Study II cohort of female nurses (N ⬎116,000) found nonsignificant associations between pregravid total physical activity and GDM risk, and between both vigorous-intensity physical activity and brisk walking, assessed at 1–5 years before pregnancy, and relative risk of GDM.47 Another study also found a non significant association, but used a very crude measure of activity.46 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 BMI45 (see Appendix A-3 online).

Cancer The Surgeon General’s report1 examined the evidence for relationships between physical activity and a range of cancers. It was concluded that regular physical activity was associated with a decreased risk of colon cancer, and that the relationship between physical activity and breast cancer was inconsistent.1 Breast cancer. Ten cohort studies were identified of physical activity and breast cancer, with evidence from pre-, peri-, and post-menopausal women15, 48 –56 (see Appendix A-4 online). Six of these showed significant trends of decreased breast cancer risk with greater levels of physical activity,15, 48, 51, 54 –56. One study found a significant trend, but non significant RRs,49 and three studies found no association.50,52,53 In most studies, the risk reduction was of the order of 10%–20%, but in the Pennsylvania College Alumni Study there was a 51% risk reduction in women aged over 55 who reported activities with a weekly energy expenditure ⱖ1000 kcal.55 With the exception of data from the French E3N study,56 the results of recent studies did not appear to support the argument that vigorous physical activity is necessary for optimal risk reduction. For example, in the Nurses’ Health Study,54 the most popular form of physical activity was walking (which comprised more than 40% of all the moderate- and vigorous-intensity activity reported). The risk reduction in that study and in the Women’s Health Initiative study51 was greater in the mixed-moderate and vigorous physical activity group than in the vigorous-intensity physical activity Am J Prev Med 2007;33(5)

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only group. Moreover, the Women’s Health Study, which ran a separate analysis for women who reported activities with an intensity ⬎6 METs, found no relationship between participation in vigorous-intensity physical activity and risk of breast cancer.49 It is unlikely that high levels of vigorous-intensity activity are required to achieve risk reduction, as few of the women included in these large cohorts reported physical activity at this level of intensity.57 Whether the relationship between physical activity and breast cancer was stronger in postmenopausal than in premenopausal women was difficult to assess, because some studies used age as a proxy indicator of menopause without assessing true menopause status. In her 2003 review of this evidence, Lee57 reported that the median RR for all studies published (including those prior to 1996) was about 0.8 for premenopausal and 0.7 for postmenopausal women. Colon cancer. The largest cohort studies of physical activity and colorectal cancer reviewed in the Surgeon General’s report1 were the men’s U.S. alumni58 and health professionals59 studies. It was concluded that both occupational and leisure-time physical activity had a protective effect on the risk of developing colon cancer, but not rectal cancer.1 Only about 10% of the participants in all the colorectal cancer studies reviewed in the Surgeon General’s report1 were women. Three new studies that examined the relationship between physical activity and colorectal cancer in women were located (see Appendix A-5 online): the Nurses’ Health Study,60 the U.S. Cancer Prevention Cohort,61 and the Norwegian Nord–Trondelag study,62 with one60 suggesting a positive association, and one61 providing equivocal results. The Nurses’ Health Study followed almost 70,000 women for 6 years and was the first to report a significant inverse association between average weekly leisure-time physical activity (based on moderate- and vigorous-intensity physical activity) and incident colon cancer in women.60 This study found that women who reported ⬎21 MET hours of physical activity per week (equivalent to about 5 hours of moderate-intensity physical activity per week) had almost half the risk of colon cancer, compared with the most sedentary women.60 There was very little difference in risk reduction between women who reported doing only vigorous-intensity physical activity, and those who reported the equivalent energy equivalent from only moderate-intensity physical activity.60 Researchers with the U.S. Cancer Prevention cohort of almost 100,000 older women (aged 50 –74 years), also found a 40% reduction in risk among women who reported more than 7 hours per week in a combination of walking and other types of activities.61 In contrast to these two U.S. reports, the Norwegian study,62 which included almost 40,000 women followed for 10 –12 years, found no independent association between phys408

ical activity and incident colon cancer, but noted that the risk of colon cancer was associated with diabetes and high blood glucose, which were both negatively associated with physical activity. Endometrial and ovarian cancers. Of the three studies of physical activity and endometrial cancer included in the Surgeon General’s report,1 one reported a decreased risk and two reported a protective effect. The Surgeon General’s report concluded that that there was insufficient information available to evaluate the possible effect of physical activity on ovarian cancer, with one study finding no association and another finding an increased risk.1 Two new studies of endometrial cancer were identified,14,63 and both indicated that physical activity might be protective for this cancer (see Appendix A-6 online). Data from the Swedish census study (more than 250,000 women) reported a trend toward increased risk of endometrial cancer with decreasing levels of occupational physical activity,14 and data from the Swedish Twin Registry showed markedly decreased incidence of endometrial cancer with increasing levels of physical activity.63 Both these studies, however, used a crude measure of physical activity, with the first14 using occupational grouping as a proxy indicator and the second63 using participants’ self report of whether they did “hardly any,” “light,” or “regular hard” exercise. Both the 15-year follow-up of the Iowa Women’s Health Study64 and the 16-year follow-up of the Nurses’ Health Study65 suggested a positive relationship between physical activity and increased risk of ovarian cancer, although only the former found significant relationships. Other cancers. The Surgeon General’s report1 did not discuss other site-specific cancers. Six studies were found that examined pancreatic, lung, renal, or bladder cancer (see Appendix A-6 online). Of the three studies of pancreatic cancer,66 – 68 one66 suggested a protective effect with increasing levels of moderate physical activity and walking/hiking. Neither of the single studies of lung cancer16 or renal cancer69 found an association. Data from the Iowa Women’s Health Study, however, did suggest that regular physical activity may be protective against bladder cancer.70 More studies are required before definitive conclusions can be made about the relationships between physical activity and these cancers.

Conclusion This review adds to the understanding of the relationships between physical activity and the prevention of cardiovascular disease, diabetes, and cancer in women, while at the same time highlighting important areas for future research. Ten years after the publication of the Surgeon General’s report,1 the evidence supporting

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the role of physical activity in the primary prevention of cardiovascular disease (including stroke) and diabetes is now seen to be as strong for women as it is for men. There is also growing support for its role in the primary prevention of colon and breast cancer. The evidence reviewed here supports an inverse dose–response relationship for these three major health outcomes, with risk reductions ranging from about 20% to 50% for the energy expenditure equivalent of at least 1 hour of moderate-intensity physical activity each week. Emerging areas of research include the role of physical activity in the primary prevention of gestational diabetes, ovarian and endometrial cancer, and site-specific cancers such as lung, renal, bladder, and pancreatic cancer. There is accumulating evidence that physical activity has a protective effect on endometrial cancer, even with very crude measures of participation. Its role in the prevention of gestational diabetes and other site-specific cancers is however, equivocal. The data in this review suggest that walking and moderate-intensity physical activity appear to confer similar benefits to those that result from more vigorousintensity physical activity, after adjustment for total energy expenditure. The statement from the Surgeon General’s report1 that vigorous activity will confer greater health benefits than moderate activity, is not supported by this review. This may reflect the fact that few of the women in these large cohort studies report doing vigorous activity, so specific risk reduction estimates for vigorous physical activity are rarely made. When they have been, they are similar to those for walking, especially for cardiovascular disease and diabetes. While vigorous activity should not be discouraged for those who wish to do it, it is not essential for middle-aged and older women to be vigorously active to achieve significant health benefits. The new studies reviewed here also show a reduction in risk of some health problems (notably CVD and diabetes) with as little as 15–30 minutes of physical activity per day. As lack of time is one of the most frequently identified barriers to physical activity participation,71 this finding has important implications for promoting physical activity, particularly among women who are “juggling” time in paid and unpaid working roles. Because duration and frequency are often subsumed in an overall measure of total physical activity, it is not possible to draw conclusions from the data presented here about the number of days per week or the minimum duration of each session that are required for health benefits. Although a recent study has reported that the relative intensity of walking, and not the duration, is important in reducing all-cause mortality,72 few of the studies reviewed here have examined issues relating to physical activity duration and frequency. For example, are cumulative 10-minute sessions of physical activity, as promoted in current recommendations, November 2007

really beneficial for health, and what are the health benefits of a single long session of activity (such as a 5-hour walk on 1 day each week), compared with shorter more frequent weekly sessions? Many of the studies reviewed here have collected information in sufficient detail to answer these questions, but have not yet examined these issues. It is clear from this review that very little is known about the contribution of occupational and domestic physical activity to the primary prevention of health problems in women. Although some studies have included domestic chores and gardening in their measures of total physical activity, few have included occupational activity as an independent study variable. The contribution of these activity domains to providing health benefits therefore remains unclear. Just as researchers are now studying walking and vigorous-intensity physical activity separately, more work is now needed to understand the potential value of the other domains of activity, such as commuting, occupational, and domestic physical activity. Because of the wide variations in measurement and reporting of physical activity in the reviewed studies, a meta-analytical study could not be conducted. Nonetheless, it is clear from this narrative review that the potential of physical activity for the prevention of major chronic health problems in women merits much greater investment in ensuring that social and cultural norms encourage and prioritize regular physical activity for all women. This work was supported by a grant from the Australian Government Department of Families, Community Services, and Indigenous Affairs. No financial disclosures were reported by the authors of this paper.

References 1. U.S. Department of Health and Human Services (USDHHS). Physical activity and health: a report of the surgeon general. Atlanta GA: USDHHS, Centers for Disease Control and Prevention (CDC), 1996. 2. Morris JN, Kagan A, Pattison DC, Gardner MJ, Raffle PAB. Incidence and prediction of ischemic heart disease in London busmen. Lancet 1966;2:553–9. 3. Morris JN, Everitt MG, Pollard R, Chave SPW, Semmence AM. Vigorous exercise in leisure time: protection against coronary heart disease. Lancet 1980;2:1207–10. 4. Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1978;108:161–75. 5. Paffenbarger RS Jr, Hale WE. Work activity and coronary heart mortality. New Engl J Med 1975;292:545–50. 6. Taylor HL, Klepetar E, Keys A, Parlin W, Blackburn H, Puchner T. Death rates among physically active and sedentary employees of the railroad industry. Am J Public Health 1962;52:1697–707. 7. Schaper AG, Wannamathee G. Physical activity and ischaemic heart disease in middle-aged British men. Br Heart J 1991;66:384 –94. 8. Ekelund LG, Haskell WL, Johnson JL, Whaley FS, Criqui MH, Sheps DS. Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men: The Lipid Research Clinics Mortality Follow-up Study. N Engl J Med 1988;319:1379 – 84. 9. Wizemann T, Pardue M, eds. Exploring the biological contributions to health: does sex matter? Washington DC: National Academy Press, 2001.

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10. Headey B, Warren D, Harding G. Families, incomes and jobs: a statistical report of the HILDA survey. Melbourne: Uni Print Pty Ltd, 2006 11. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global burden of disease and risk factors. Geneva, Switzerland: World Bank Publications, 2006. 12. Weller I, Corey P. The impact of excluding non-leisure energy expenditure on the relation between physical activity and mortality in women. Epidemiology 1998;9: 632–5. 13. Brown WJ, Trost SG, Ringuet C, Jenkins D. Measurement of energy expenditure of daily tasks among mothers of young children. J Sci Med Sport 2001;4: 379 – 85. 14. Moradi T, Nyren O, Bergstrom R, et al. Risk for endometrial cancer in relation to occupational physical activity: a nationwide cohort study in Sweden. Int J Cancer 1998;76:665–70. 15. Thune I, Brenn T, Lund E, Gaard M. Physical activity and the risk of breast cancer. N Engl J Med 1997;336:1269 –75. 16. Thune I, Lund E. The influence of physical activity on lung cancer risk. Int J Cancer 1997;70:57– 62. 17. Manson JE, Greenland P, LaCroix AZ, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002;347:716 –25. 18. Dorn JP, Cerny FJ, Epstein H, et al. Work and leisure time physical activity and mortality in men and women from a general population sample. Ann Epidemiol 1999;9:366 –73. 19. Ellekjaer H, Holman J, Ellekjar E, Vatten L. Physical activity and stroke mortality in women: 10-year follow-up of the Nord-Trondelag Health Survey 1984 –1986. Stroke 2000;31:14 –18. 20. Folsom AR, Arnett DK, Hutchison RG, Liao F, Clegg LX, Cooper LS. Physical activity and incidence of coronary heart disease in middle aged women and men. Med Sci Sports Exerc 1997;29:901–9. 21. Gregg EW, Cauley JA, Stone K, et al. Relationship of changes in physical activity and mortality among older women. JAMA 2003;289:2379 – 86. 22. Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. Association of leisure time physical activity with the risk of coronary heart disease, hypertension, and diabetes in middle aged men and women. Int J Epidemiol 1997;26:739 – 47. 23. Haapanen-Niemi N, Miilunpalo S, Pasanen M, Vuori I, Oja P, Malmberg J. Body mass index, physical inactivity and low level of physical fitness as determinants of all cause and cardiovascular disease mortality – 16 year follow up of middle aged and elderly men and women. Int J Obes 2000;24:1465–74. 24. He, J, Ogden L, Bazzana L, Vupputuri S, Loria C, Whelton P. Risk factors for congestive heart failure in U.S. men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001;161:996 –1002. 25. Hu FB, Stampfer MJ, Colditz GA, et al. Physical activity and risk stroke in women. JAMA 2000;283:2961–7. 26. Kushi LH, Fee RM, Folsom AR, Mink PJ, Anderson KE, Sellers TA. Physical activity and mortality in postmenopausal women. JAMA 1997;277:1287–92. 27. Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women: is ”no pain, no gain” passé? JAMA 2001;285:1447–54. 28. 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. N Engl J Med 1999;341:650 – 8. 29. Nakayama T, Date C, Yokoyama T, Yoshiike N, Yamaguchi M, Tanaka H. A 15.5 year follow-up of stroke in a Japanese provincial city. Stroke 1997;28:45–52. 30. Paganini-Hill A, Barreto MP. Stroke risk in older men and women: aspirin, estrogen, exercise, vitamins and other factors. J Gend Specif Med 2001;4:18 –28. 31. Rockhill B, Willett WC, et al. Physical activity and mortality: a prospective study among women. Am J Public Health 2001;91:578 – 83. 32. Sesso HD, Paffenbarger RS, Ha T, Lee IM. Physical activity and cardiovascular disease risk in middle-aged and older women. Am J Epidemiol 1999;150:408 –16. 33. Helmrich SP, Ragland DR, Leung RW, Paffenbarger RS Jr. Physical activity and reduced occurrence of non insulin dependent diabetes mellitus. N Engl J Med 1991;325:147–52. 34. Manson JE, Nathan DM, Krolewski AS, Stampfer MJ, Willett WC, Hennekens CH. A prospective study of exercise and incidence of diabetes among U.S. male physicians. JAMA 1992;268:3– 67. 35. Manson JE, Rimm EB, Stampfer MJ, et al., Physical activity and non insulin dependent diabetes mellitus in women. Lancet 1991;338:774 – 8.

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36. Dotevall A, Johansson S, Wihelmsen L, Rosengren A. Increased levels of triglycerides, BMI and blood pressure and low physical activity increase the risk of diabetes in Swedish women. A prospective 18 year follow up of the BEDA study. Diabet Med 2004;21:615–22. 37. Folsom AR, Kushi LH, Hong CP. Physical activity and incident diabetes mellitus in post menopausal women. Am J Public Health 2000;90:134 – 8. 38. Hsia J, Wu L, Allen C, et al. Physical activity and diabetes risk in post menopausal women. Am J Prev Med 2005;28:19 –25. 39. Hu FB, Li TY, Colditz GA, Willett WC, Manson JE. Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA 2003;289:1785–91. 40. Hu FB, Sigal RJ, Rich-Edwards JW, et al. Walking compared with vigorous physical activity and risk of type 2 diabetes in women. JAMA 1999;282:1433–39. 41. Kriska AM, Saremi A, Hanson RL, et al. Physical activity, obesity, and the incidence of type 2 diabetes in a high risk population. Am J Epidemiol 2003:158:669 –75. 42. Weinstein AR, Sesso HD, Lee IM, et al. Relationship of physical activity vs body mass index with type 2 diabetes in women. JAMA 2004;292:1188 –94. 43. Cheung NW, Byth K. Population health significance of gestational diabetes. Diabetes Care 2003;27:2005–9. 44. O’Sullivan J. Diabetes mellitus after gestational diabetes mellitus. Diabetes 1991;29:131–5. 45. Dempsey JC, Sorensen TK, Willaims MA, et al. Prosepective study of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and during pregnancy. Am J Epidemiol 2004;159:663–70. 46. Dye TD, Knox KL, Artal R, Aubry RH, Wojtowycz MA. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997;146:961–5. 47. Solomon CG, Willett WC, Carey VJ, et al. A prospective study of pregravid determinants of gestational diabetes mellitus. JAMA 1997;278:1078 – 83. 48. Breslow RA, Ballard-Barbash R, Munoz K, Graubard BI. Long term recreational physical activity and breast cancer in the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Cancer Epidemiol Biomarkers Prev 2001;10:805– 8. 49. Lee IM, Rexrode KM, Cook NR, Hennekens CH, Burting JE. Physical activity and breast cancer risk: the Women’s Health Study (United States). Cancer Causes Control 2001;12:137– 45. 50. Luoto R, Latikka P, Pukkala E, Hakulinen T, Vihko V. The effect of physical activity on breast cancer risk: a cohort study of 30,548 women. Eur J Epidemiol 2001;16:973– 80. 51. McTiernan A, Kooperberg C, White E, et al. Recreational physical activity and the risk of breast cancer in postmenopausal women: The Women’s Health Initiative Cohort Study. JAMA 2003;290:1331– 6. 52. Moore DB, Folsom AR, Mink PJ, Hong C, Anderson KE, Kushi LH. Physical activity and incidence of post menopausal breast cancer. Epidemiology 2000;11:292–96. 53. Rockhill B, Willett WC, Hunter DJ, et al. Physical activity and breast cancer risk in a cohort of young women. J Nat Cancer Inst 1998;90:1155– 60. 54. Rockhill B, Willett WC, Hunter DJ, Manson JE, Hankinson SE, Colditz GA. A prospective study of recreational physical activity and breast cancer risk. Arch Intern Med 1999;159:2290 – 6. 55. Sesso HD, Paffenbarger RS Jr, Lee IM. Physical activity and breast cancer risk in the College Alumni Health Study (United States). Cancer Causes Control 1998;9:433–9. 56. Tehard B, Friedenreich CM, Oppert JM, Clavel-Chapelon F. Effect of physical activity on women at increased risk of breast cancer: results from the E3N Cohort Study. Cancer Epidemiol Biomarkers Prev 2006;15:57– 64. 57. Lee IM. Physical activity and cancer prevention— data from epidemiologic studies. Med Sci Sports Exerc 2003;35:1823–27. 58. Paffenbarger RS Jr, Hyde RT, Wing AL. Physical activity and incidence of cancer in diverse populations: a preliminary report. Am J Clin Nutr 1987;45:312–7. 59. Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer M,Willett WC. Physical activity, obesity, and risk for colon cancer and adenoma in men. Ann Intern Med 1995;122:327–34. 60. Martinez ME, Giovannucci E, Spiegelman D, Hunter DJ, Willett WC, Colditz GA. Leisure time physical activity, body size, and colon cancer in women. J Nat Cancer Inst 1997;89:948 –55. 61. Chao A, Connell CJ, Jacobs EJ, et al. Amount, type, and timing of recreational physical activity in relation to colon and rectal cancer in older adults: the Cancer Prevention Study II Nutrition Cohort. Cancer Epidemiol Biomarkers Prev 2004;13:2187–95. 62. Lund Nilsen TI, Vatten LJ. Prospective study of colorectal cancer risk and physical activity, diabetes, blood glucose and BMI: exploring the hyperinsulinaemia hypothesis. Br J Cancer 2001;84:417–22.

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63. Terry P, Baron JA, Weiderpass E, Yuen J, Lichtenstein P, Nyren O. Lifestyle and endometrial cancer risk: a cohort study from the Swedish twin registry. Int J Cancer 1999;82:38 – 42. 64. Anderson JP, Ross JA, Folsom AR. Anthropometric variables, physical activity and incidence of ovarian cancer. The Iowa Women’s Health Study. Cancer 2004;100:1515–21. 65. Bertone ER, Willett WC, Rosner BA, et al. Prospective study of recreational physical activity cancer and ovarian cancer. J Nat Cancer Inst 2001; 93:942– 8. 66. Michaud DS, Giovannucci E, Willett WC, Colditz GA, Stampfer MJ, Fuchs CS. Physical activity, obesity, height, and the risk of pancreatic cancer. JAMA 2001;286:921–9. 67. Patel AV, Rodriguez C, Bernstein L, Chao A, Thun MJ, Calle EE. Obesity, recreational physical activity and risk of pancreatic cancer in a large U.S. cohort. Cancer Epidemiol Biomarkers Prev 2005; 14:459 – 66.

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68. Sinner PJ, Schmitz KH, Anderson KE, Folsom AR. Lack of association of physical activity and obesity with incident pancreatic cancer in elderly women. Cancer Epidemiol Biomarkers Prev 2005;14:1571–3. 69. Van Dijk BAC, Schouten LJ, Kiemeney LALM, Goldbohm RA, van den Brandt PA. Relation of height, body mass, energy intake, and physical activity to risk of renal cell carcinoma: results from the Netherlands Cohort Study. Am J Epidemiol 2004;160:1159 – 67. 70. Tripathi A, Folsom AR, Anderson KE. Risk factors for urinary bladder carcinoma in post menopausal women. The Iowa Women’s Study. Cancer 2002;95:2316 –23. 71. Brownson RC, Baker EA, Housemann RA, Brennan LK, Bacak SJ. Environmental and policy determinants of physical activity in the United States. Am J Public Health 2001;91:1995–2003. 72. Schnohr P, Scharling H, Jensen JS. Intensity versus duration of walking, impact on mortality: the Copenhagen City Heart Study. Eur J Cardiovas Prev Rehabil 2007;14:72– 8.

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Appendix Appendix References 1. Dorn JP, Cerny FJ, Epstein H, et al. Work and leisure time physical activity and mortality in men and women from a general population sample. Ann Epidemiol 1999;9: 366 –73. 2. Ellekjaer H, Holman J, Ellekjar E, Vatten L. Physical activity and stroke mortality in women: ten year follow up of the Nord-Trondelag Health Survey 1984 –1986. Stroke 2000;31:14 – 8. 3. Folsom AR, Arnett DK, Hutchison RG, Liao F, Clegg LX, Cooper LS. Physical activity and incidence of coronary heart disease in middle aged women and men. Med Sci Sports Exerc 1997;29:901–9. 4. Gregg EW, Cauley JA, Stone K, et al. Relationship of changes in physical activity and mortality among older women. JAMA 2003;289:2379 – 86. 5. Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. Association of leisure time physical activity with the risk of coronary heart disease, hypertension, and diabetes in middle aged men and women. Internat J Epidemiol 1997;26:739 – 47. 6. Haapanen-Niemi N, Miilunpalo S, Pasanen M, Vuori I, Oja P, Malmberg J. Body mass index, physical inactivity and low level of physical fitness as determinants of all cause and cardiovascular disease mortality – 16 year follow up of middle aged and elderly men and women. Int J Obes 2000;24:1465–74. 7. He, J, Ogden L, Bazzana L, Vupputuri S, Loria C, Whelton P. Risk factors for congestive heart failure in US men and women: NHANES I Epidemiologic Follow-up study. Arch Intern Med, 2001;161:996 –1002. 8. Hu FB, Stampfer MJ, Colditz GA, et al. Physical activity and risk stroke in women. JAMA, 2000;283:2961–7. 9. Kushi LH, Fee RM, Folsom AR, Mink PJ, Anderson KE, Sellers TA. Physical activity and mortality in post menopausal women. JAMA 1997;277:1287–92. 10. Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women: is ”no pain, no gain” passé? JAMA 2001;285:1447–54. 11. Manson JE, Greenland P, LaCroix AZ, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002;347:716 –25. 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. N Engl J Med 1999;341:650 – 8. 13. Nakayama T, Date C, Yokoyama T, Yoshiike N, Yamaguchi M, Tanaka H. A 15.5 year follow-up of stroke in a Japanese provincial city. Stroke 1997;28:45–52. 14. Paganini-Hill A, Barreto MP. Stroke risk in older men and women: aspirin, estrogen, exercise, vitamins and other factors. J Gend Specif Med 2001;4:18 –28. 15. Rockhill B, Willett WC, Manson JE, Leitzmann MF, Stampfer MJ, Hunter DJ, Coldtidz GA. Physical activity and mortality: a prospective study among women. Am J Public Health 2001;91:578 – 83. 16. Sesso HD, Paffenbarger RS, Ha T, Lee IM. Physical activity and cardiovascular disease risk in middle-aged and older women. Am J Epidemiol, 1999;150:408 –16. 17. Weller I, Corey P. The impact of excluding non-leisure energy expenditure on the relation between physical activity and mortality in women. Epidemiol 1998;9:632–5. 18. Dotevall A, Johansson S, Wihelmsen L, Rosengren A. Increased levels of triglycerides, BMI and blood pressure and low physical activity increase the risk of diabetes in Swedish women. A prospective 18-year follow-up of the BEDA study. Diabetic Med 2004; 21:615–22. 19. Folsom AR, Kushi LH, Hong CP. Physical activity and incident diabetes mellitus in post menopausal women. Am J Public Health 2000;90:134 – 8. 20. Hsia J, Wu L, Allen C, et al. Physical activity and diabetes risk in post menopausal women. Am J Prev Med 2005;28:19 –25. 21. Hu FB, Li TY, Colditz GA, Willett WC, Manson JE. Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA 2003;289:1785–91. 22. Hu FB, Sigal RJ, Rich-Edwards JW, et al. Walking compared with vigorous physical activity and risk of type 2 diabetes in women. JAMA 1999;282:1433–39. 23. Kriska AM, Saremi A, Hanson RL, et al. Physical activity, obesity, and the incidence of type 2 diabetes in a high risk population. Am J Epidemiol 2003:158:669 –75. 24. Weinstein AR, Sesso HD, Lee IM, et al. Relationship of physical activity vs body mass index with type 2 diabetes in women. JAMA 2004;292:1188 –94.

25. Dempsey JC, Sorensen TK, Willaims MA, et al. Prosepective study of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and during pregnancy. Am J Epidemiol 2004;159:663–70. 26. Dye TD, Knox KL, Artal R, Aubry RH, Wojtowycz MA. Physical activity, obesity, and diabetes in pregnancy. Am J Epidemiol 1997;146:961–5. 27. Solomon CG, Willett WC, Carey VJ, et al. A prospective study of pregravid determinants of gestational diabetes mellitus. JAMA 1997;278:1078 – 83. 28. Breslow RA, Ballard-Barbash R, Munoz K, Graubard BI. Long term recreational physical activity and breast cancer in the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Cancer Epidemiol Biomarkers Prev 2001;10:805– 8. 29. Lee IM, Rexrode KM, Cook NR, Hennekens CH, Burting JE. Physical activity and breast cancer risk: the Women’s Health Study (United States). Cancer Causes Control 2001;12:137– 45. 30. Luoto R, Latikka P, Pukkala E, Hakulinen T, Vihko V. The effect of physical activity on breast cancer risk: a cohort study of 30,548 women. Eur J Epidemiol 2001;16:973– 80. 31. McTiernan A, Kooperberg C, White E, et al. Recreational physical activity and the risk of breast cancer in postmenopausal women: The Women’s Health Initiative Cohort Study. JAMA 2003;290:1331– 6. 32. Moore DB, Folsom AR, Mink PJ, Hong C, Anderson KE, Kushi LH. Physical activity and incidence of post menopausal breast cancer. Epidemiol 2000; 11: 292–96. 33. Rockhill B, Willett WC, Hunter DJ, et al. Physical activity and breast cancer risk in a cohort of young women. J Nat Cancer Inst 1998;90:1155– 60. 34. Rockhill B, Willett WC, Hunter DJ, Manson JE, Hankinson SE, Colditz GA. A prospective study of recreational physical activity and breast cancer risk. Arch Intern Med 1999;159:2290 –96. 35. Sesso HD, Paffenbarger RS Jr, Lee IM. Physical activity and breast cancer risk in the College Alumni Health Study (United States). Cancer Causes Control 1998;9:433–9. 36. Tehard B, Friedenreich CM, Oppert JM, Clavel-Chapelon F. Effect of physical activity on women at increased risk of breast cancer: results fro the E3N Cohort Study. Cancer Epidemiol Biomarkers Prev 2006;15:57– 64. 37. Thune I, Brenn T, Lund E, Gaard M. Physical activity and the risk of breast cancer. N Engl J Med 1997;336:1269 –75. 38. Chao A, Connell CJ, Jacobs EJ, et al. Amount, type, and timing of recreational physical activity in relation to colon and rectal cancer in older adults: the Cancer Prevention Study II Nutrition Cohort. Cancer Epidemiol Biomarkers Prev 2004;13:2187–95. 39. Lund Nilsen TI, Vatten LJ. Prospective study of colorectal cancer risk and physical activity, diabetes, blood glucose and BMI: exploring the hyperinsulinaemia hypothesis. Br J Cancer 2001;84:417–22. 40. Martinez ME, Giovannucci E, Spiegelman D, Hunter DJ, Willett WC, Colditz GA. Leisure time physical activity, body size, and colon cancer in women. J Nat Cancer Inst 1997;89:948 –55. 41. Anderson JP, Ross JA, Folsom AR. Anthropometric variables, physical activity and incidence of ovarian cancer. The Iowa Women’s Health Study. Cancer 2004;100:1515–21. 42. Bertone ER, Willett WC, Rosner BA, et al. Prospective study of recreational physical activity cancer and ovarian cancer. J Nat Cancer Inst 2001;93:942– 8. 43. Michaud DS, Giovannucci E, Willett WC, Colditz GA, Stampfer MJ, Fuchs CS. Physical activity, obesity, height, and the risk of pancreatic cancer. JAMA 2001;286:921–9. 44. Moradi T, Nyren O, Bergstrom R, et al. Risk for endometrial cancer in relation to occupational physical activity: a nationwide cohort study in Sweden. Int J Cancer 1998;76:665–70. 45. Patel AV, Rodriguez C, Bernstein L, Chao A, Thun MJ, Calle EE. Obesity, recreational physical activity and risk of pancreatic cancer in a large U.S. cohort. Cancer Epidemiol Biomarkers Prev 2005;14:459 – 66. 46. Sinner PJ, Schmitz KH, Anderson KE, Folsom AR. Lack of association of physical activity and obesity with incident pancreatic cancer in elderly women. Cancer Epidemiol Biomarkers Prev 2005;14:1571–3. 47. Terry P, Baron JA, Weiderpass E, Yuen J, Lichtenstein P, Nyren O. Lifestyle and endometrial cancer risk: a cohort study from the Swedish twin registry. Int J Cancer 1999;82:38 – 42. 48. Thune I, Lund E. The influence of physical activity on lung cancer risk. Int J Cancer 1997;70:57– 62. 49. Tripathi A, Folsom AR, Anderson KE. Risk factors for urinary bladder carcinoma in post menopausal women. The Iowa Women’s Study. Cancer 2002;95:2316 –23. 50. Van Dijk BAC, Schouten LJ, Kiemeney LALM, Goldbohm RA, van den Brandt PA. Relation of height, body mass, energy intake, and physical activity to risk of renal cell carcinoma: results from the Netherlands Cohort Study. Am J Epidemiol 2004;160:1159 – 67.

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411.e1

Appendix A-1. Population-based studies of the association between physical activity and coronary heart disease/cardiovascular disease

Reference

Study/location, number & age of women

Dorn et al. (1999)1

Buffalo Health Study (U.S.) N ⫽ 763 15–96 years of age in 1960 ⬍60 years of age (n ⫽ 613) ⬎60 years of age (n ⫽ 150)

Ellekjaer et al. (2000)2

Nord-Trondelag Health Survey (Norway) N ⫽ 14, 101 50 – 69 years of age (n ⫽ 9460) 70 –79 years of age (n ⫽ 3417) 80 –101 years of age (n ⫽ 1224)

Folsom et al. (1997)3

Gregg et al. (2003)4

411.e2

Atherosclerosis Risk in Communities Study (U.S.). N ⫽ 7852 45– 64 years of age

Study of Osteoporotic Fractures (U.S.) N ⫽ 7,553 ⱖ65 years of age

Physical activity measurement Interview: 1960-61 ● Number of workday hours sitting, standing, carrying or lifting objects ⬎25 pounds, digging, work exercise activities, sleeping ● Number of blocks walked during workday ● Number of weekend hours sitting, lying down, standing, sports, exercise such as gardening ● Number of blocks walked (weekend day) Measure ● Total PA energy expenditure (kcal/kg/hr) Questionnaire: 1984-6 ● Weekly frequency of exercise (including walking) ● Intensity of exercise ● Duration of each exercise session Measure ● Physical activity level: low (⬍1x/wk), medium (⬍median), high (⬎median)

Interview: 1987-89 Sports PA in past year ● Frequency, duration, intensity ● Frequency of sweating, playing sports, self comparison with others Leisure PA in past year ● Frequency of television, walking, cycling, walking/ cycling to work/shopping Measure Quartiles (values not given) ● Sports PA ● Leisure PA Questionnaire: 1986-8, 1992-4 ● Frequency and duration of leisure PA (including gardening) in past year ● Number city blocks walked daily Measure ● Total PA energy expenditure quintiles (kcal/wk) ● Walking energy expenditure quintiles (kcal/wk) ● PA change (1986-8 and 1992-4, median 5.7 years): stayed sedentary (lowest 40%, ⬍595kcal/wk), became active (moved from lowest 40% to highest 60%), became sedentary (moved from highest 60% to lowest 40%), stayed active

Outcome, follow-up period, adjustments

Summary of results (95% confidence interval)

Coronary heart disease mortality 29 years Age, education, cigarettes, BP

For each unit increase in total PA energy expenditure (kcal/kg/hour) Aged ⬍60 years 0.42 (0.11–1.52) Aged ⱖ60 years 1.78 (0.77– 4.09)

Stroke mortality 10 years Age, smoking, diabetes, BMI, antihypertensive medication, SBP, angina pectoris, myocardial infarction, illness impairing function, education

PA level, all women Low Medium High p trend ⫽ 0.0001 PA level, 50–69 years Low Medium High p trend ⫽ 0.0021 PA level, 70–79 years Low Medium High p trend ⫽ 0.0093 PA level, 80–101 years Low Medium High p trend ⫽ 0.108 Sports PA Lowest 2nd quartile 3rd quartile Highest p trend ⫽ 0.04 Leisure PA Lowest 2nd quartile 3rd quartile Highest p trend ⫽ 0.37 Total PA (kcal/wk) ⬍163 163–503 504–1045 1046–1906 ⱖ1907 Walking (kcal/wk) ⬍70 70–186 187–419 420–897 ⱖ898 PA change Stayed sedentary Became active Became sedentary Stayed active

Coronary heart disease incident events (MI or death) 4 –7 years Age, education, smoking, alcohol, HRT, race, study centre, diabetes, waist hip ratio, T-C, HDL-C, SBP, antihypertensive medication, fibrinogen Cardiovascular disease mortality 12.5 years Age, smoking, BMI, stroke, diabetes, hypertension, self rated health at baseline, cancer, chronic obstructive pulmonary disease, incident hip fracture, baseline PA

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1.00 0.77 (0.61–0.98) 0.52 (0.30–0.72)

1.00 0.57 (0.34–0.95) 0.42 (0.24–0.75)

1.00 0.79 (0.55–1.12) 0.56 (0.36–0.88)

1.00 0.91 (0.60–1.39) 0.57 (0.30–1.09)

1.00 0.96 (0.49–1.92) 0.51 (0.21–1.21) 0.49 (0.21–1.31)

1.00 0.74 (0.42–1.21) 1.07 (0.55–2.09) 0.64 (0.34–1.24)

1.00 0.65 (0.53–0.79) 0.70 (0.57–0.85) 0.60 (0.48–0.75) 0.58 (0.46–0.74) 1.00 0.88 (0.73–1.06) 0.66 (0.53–0.82) 0.68 (0.55–0.84) 0.61 (0.49–0.78) 1.00 0.64 (0.42–0.97) 1.07 (0.81–1.42) 0.62 (0.44–0.88)

Appendix A-1. continued

Reference Haapanen et al. (1997)5

HaapanenNiemi et al. (2000)6

Study/location, number & age of women Finland N ⫽ 953 35– 63 years of age in 1980

Finland N ⫽ 1122 35– 63 years of age in 1980 51–79 years of age in 1996

He et al. (2001)7

NHANES I Epidemiologic Followup Study (U.S.) N ⫽ 8098 25–74 years of age in 1971 and 1975 Mean 48.1 years

Hu et al. (2000)8

Nurses’ Health Study (U.S.) N ⫽ 72,488 40 – 65 years of age in 1986

Physical activity measurement Questionnaire: 1980 ● Frequency and duration of exercise, sports, physical recreation ● Frequency and duration of household chores ● Frequency and duration of commuting to and from work Measure ● Total PA energy expenditure (kcal/wk) ● Frequency of vigorous PA (frequency/wk) Questionnaire: 1980 ● Weekly frequency and duration in past year of exercise, sports, physical recreation, ● Weekly frequency and duration in past year of leisure time and household chores, ● Weekly frequency and duration in past year of commuting to and from work ● Global description of PA during past year ● Ability to walk 2km ● Ability to walk 2km and climb several stair flights without rest Measure ● Total PA energy expenditure (kcal/wk) ● Global leisure PA/wk: active (vigorous PA ⱖ1/wk and some light PA), inactive (no or light intensity PA) ● Ability to walk 2km ● Ability to walk and climb stairs Interview: 1971-5 Measure ● Leisure PA level: low, medium or high (no values)

Questionnaire: 1980 ● Average hr/wk in past year in moderate and vigorous PA (including gardening, brisk walking) Questionnaire: 1980 ● Average hr/wk in past year in strenuous PA Questionnaire: 1986, 1988, 1992 ● Average time/wk spent walking, jogging, running, bicycling, calisthenics, aerobics, rowing, lap swimming, racquet sports ● Usual walking pace ● Hr/wk in strenuous PA Measure ● Total PA energy expenditure quintiles (MET.hr/wk) ● Walking energy expenditure quintiles (MET.hr/wk) ● Usual walking pace (km/hr) ● Change in PA between 1980 and 1986 (for each 3.5 hr/wk increase)

Outcome, follow-up period, adjustments

Summary of results (95% confidence interval)

Coronary heart disease incidence and mortality 10 years Age, smoking

Total PA (kcal/wk) 0 –900 901–1500 ⬎1500 p trend ⫽ 0.178 vPA (x/wk) ⱖ1x ⬎1x p trend ⫽ 0.694

Cardiovascular disease mortality 16 years Age, marital status, employment status, perceived health, smoking status, alcohol consumption

Congestive heart failure (CHF) 7–21 years Average 19 years Race, CHD history, education, smoking, alcohol, BP, hypertension, cholesterol, overweight, diabetes, valvular disease Stroke 8 years Age, time, smoking, BMI, menopausal status, parental history of MI, alcohol, aspirin, diabetes history, hypertension history, hypocholesterolemia history

Total PA (kcal/wk) 0 – 800 800.1–1500 ⬎1500 p ⫽ 0.046 Global leisure PA vPA ⱖ1/wk, light PA no/light PA p ⫽ 0.002 Walk 2km ability No difficulty Some difficulty p ⫽ 0.614 Stair climbing ability No difficulty Some difficulty p ⫽ 0.13

PA level Medium/High Low p ⫽ 0.002

1.00 0.73 (0.38 –1.39) 1.25 (0.72–2.15) 1.00 1.13 (0.62–2.07)

1.00 0.43 (0.16 –1.16) 1.17 (0.51–2.68) 1.00 4.68 (1.41–15.57) 1.00 1.25 (0.53–2.90) 1.00 3.38 (1.22–9.41)

1.00 1.31 (1.11–1.54)

Total PA (MET.hr/wk) ⬍2.0 1.00 2.1–4.6 0.98 (0.75–1.29) 4.7–10.4 0.82 (0.61–1.10) 10.5–21.7 0.74 (0.54–1.01) ⬎21.7 0.66 (0.47–0.91) p trend ⫽ 0.005 Walking (MET.hr/wk) ⱕ0.5 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) ⱖ10 0.66 (0.48–0.91) p trend ⫽ 0.01 Walking pace (km/hr) ⬍3.2 1.00 3.2–4.6 0.81 (0.63–1.03) ⬎4.6 0.49 (0.36–0.68) p trend ⬍0.001 For each 3.5 hr/wk increase in mPA and vPA 0.81 (0.68–0.98) p⫽0.03

Am J Prev Med 2007;33(5)

411.e3

Appendix A-1. continued

Reference Kushi et al. (1997)9

Lee et al. (2001)10

411.e4

Study/location, number & age of women Iowa Women’s Health Study (U.S.) N ⫽ 40,417 55– 69 years in 1986

Women’s Health Study (U.S. and Puerto Rico) N ⫽ 39,372 ⱖ45 years of age

Outcome, follow-up period, adjustments

Summary of results (95% confidence interval)

Questionnaire: 1986 ● Any regular daily leisure time PA (not occupational or domestic) to keep physically fit ● Frequency and duration of moderate PA (including gardening and walks) ● Frequency and duration of vigorous PA Measure ● Daily PA ● Moderate PA frequency ● Vigorous PA frequency ● PA level: low (vPA ⬍1x/wk or mPA ⬍1x/wk), medium (vPA 1x/wk or mPA 1– 4x/ wk), high (vPA ⱖ2x/wk or mPA ⱖ4x/wk)

Cardiovascular disease mortality 7 years Age, menarche age, menopause age, age at first live birth, parity, alcohol, total energy intake, smoking, estrogen use, BMI at baseline, BMI at age 18, waist to hip ratio, education, marital status

Questionnaire: 1992-5 ● Average time per week spent in the past year: walking/hiking, jogging, running, bicycling, aerobic exercises, low-intensity exercise, racquet sports, lap swimming ● Usual walking pace ● Number of flights of stairs climbed daily Measure ● Total PA energy expenditure (kcal/wk) ● Vigorous PA energy expenditure (kcal/wk) ● Walking time/wk (excludes vPA) ● Walking pace (km/hr)

Coronary heart disease 4 –7 years Average 5 years Study condition, smoking status, alcohol consumption, saturated fat intake, fibre intake, fruit and vegetable consumption, menopausal status, hormone use, parental MI history, BMI, hypertension, elevated cholesterol, diabetes

Daily PA No Yes mPA (frequency) Rarely/never 1x/wk, few/mo 2–4x/wk ⬎4x/wk p trend ⫽ 0.003 vPA (frequency) Rarely/never 1/wk, few/mo 2–4x/wk ⬎4x/wk p trend ⫽ 0.09 PA level (frequency) Low Medium High p trend ⫽ 0.002 Total PA (kcal/wk) ⬍200 200–599 600–1499 ⱖ1500 p trend ⫽ 0.03 vPA (kcal/wk) 0 & ⬍200 other PA 0 & ⱖ200 other PA 1–199 vPA 200–499 vPA ⱖ500 vPA p trend ⫽ 0.45 Walking time (/wk) No walking 1–59mins 1.0–1.5 hrs ⬎2hrs p trend ⫽ 0.001 Walking pace (km/hr) No walking ⬍3.2 3.2–4.7 ⱖ4.8 p trend ⫽ 0.02

Physical activity measurement

American Journal of Preventive Medicine, Volume 33, Number 5

1.00 0.72 (0.54–0.95) 1.00 0.86 (0.61–1.21) 0.74 (0.52–1.05) 0.53 (0.34–0.82)

1.00 0.85 (0.50–1.44) 0.59 (0.28–1.25) 0.20 (0.03–1.41)

1.00 0.86 (0.63–1.17) 0.55 (0.38–0.81)

1.00 0.79 (0.56–1.12) 0.55 (0.37–0.82) 0.75 (0.50–1.12)

1.00 0.65 (0.46–0.91) 1.18 (0.79–1.78) 0.96 (0.60–1.55) 0.63 (0.38–1.04)

1.00 0.86 (0.52–1.29) 0.49 (0.28–0.86) 0.48 (0.29–0.78)

1.00 0.56 (0.32–0.97) 0.71 (0.47–1.05) 0.52 (0.30–0.90)

Appendix A-1. continued

Reference Manson et al. (2002)11

Study/location, number & age of women Women’s Health Initiative Observational Study (U.S.) N ⫽ 73,743 50 –79 years of age between 1994 and 1998

Physical activity measurement Questionnaire: 1994-98 ● Frequency of strenuous, moderate, mild PA ● Frequency and duration of walking ● Usual walking pace Measure ● Total PA energy expenditure quintiles (MET.hr/wk) ● Walking energy expenditure quintiles (MET.hr/wk) ● Vigorous PA time (vPA) quintiles (mins/wk) ● Walking pace (m/hr)

Outcome, follow-up period, adjustments

Summary of results (95% confidence interval)

Cardiovascular disease 5.9 years (mean 3.2yrs) Age, smoking, BMI, waist/hip ratio, alcohol, age at menopause, HRT, parental history MI, ethnicity, education, family income, dietary variables

Total PA (MET.hr/wk) 0–2.4 1.00 2.5–7.2 0.89 (0.75–1.04) 7.3–13.4 0.81 (0.68–0.97) 13.5–23.3 0.78 (0.66–0.93) ⱖ23.4 0.72 (0.59–0.87) p trend ⬍ 0.001 Walking (MET.hr/wk) 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 trend ⬍ 0.001 vPA (mins/wk) 0 1.00 1–60 0.91 (0.73–1.12) 61–100 0.81 (0.63–1.06) 101–150 0.85 (0.64–1.13) ⬎150 0.76 (0.58–1.00) p trend ⫽ 0.01 Total PA (MET.hr/wk) 0–2.4 1.00 2.5–7.2 0.73 (0.53–0.99) 7.3–13.4 0.69 (0.51–0.95) 13.5–23.3 0.68 (0.50–0.93) ⱖ23.4 0.47 (0.33–0.67) p trend ⬍ 0.001 Walking (MET.hr/wk) 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 trend ⫽ 0.004 vPA (mins/wk) 0 1.00 1–60 1.12 (0.79–1.60) 61–100 0.56 (0.32–0.98) 101–150 0.73 (0.43–1.25) ⬎150 0.58 (0.34–0.99) p trend ⫽ 0.008

Coronary Heart Disease 5.9 years (mean 3.2yrs) Age, smoking, BMI, waist/hip ratio, alcohol, age at menopause, HRT, parental history MI, ethnicity, education, family income, dietary variables

Am J Prev Med 2007;33(5)

411.e5

Appendix A-1. continued

Reference

Study/location, number & age of women

Physical activity measurement

Outcome, follow-up period, adjustments

Summary of results (95% confidence interval) Total PA (MET.hr/wk) ⬍2.0 1.00 2.1–4.6 0.88 (0.71–1.10) 4.7–10.4 0.81 (0.64–1.02) 10.5–21.7 0.74 (0.58–0.95) ⬎21.7 0.66 (0.51–0.86) p trend ⫽ 0.002 Walking (excluding vPA) (MET.hr/wk) ⱕ0.5 1.00 0.6–2.0 0.78 (0.57–1.06) 2.1–3.8 0.88 (0.65–1.21) 3.9–10 0.70 (0.51–0.95) ⬎10.0 0.65 (0.47–0.91) p trend⫽0.02 Walking pace (km/hr) ⬍3.2 1.00 3.2–4.6 0.75 (0.59–0.96) ⬎4.6 0.64 (0.47–0.88) Walking (W) & vPA (V) (MET.hr/wk) W0–0.6 & V0 1.00 W0–0.6 & V0.1–6.9 0.78 (0.55–1.09) W0–0.6 & V ⱖ 7 0.76 (0.49–1.17) W0.7–6.9 & V0 0.84 (0.67–1.06) W0.7–6.9 & V0.1–6.9 0.86 (0.65–1.13) W0.7–6.9 & V ⱖ 7 0.59 (0.42–0.82) W ⱖ 7 & V0 0.74 (0.57–0.97) W ⱖ 7 & V0.1–6.9 0.56 (0.36–0.88) Wⱖ7&Vⱖ7 0.70 (0.51–0.95) Total PA Moderate 1.00 Light 1.95 (1.03–3.68)

Manson et al. (1999)12

Nurses’ Health Study (U.S.) N ⫽ 72,488 40 – 65 years of age in 1986

Questionnaire: 1986 ● Average time/wk in past year: walking/hiking, jogging, running, bicycling, aerobic exercises, lowintensity exercise, racquet sports, lap swimming ● Usual walking pace ● Number of flights of stairs climbed daily ● Average number of hours in moderate or vigorous PA (including gardening and walking) in previous year Measure ● Total PA energy expenditure quintiles (MET.hr/wk) ● Walking energy expenditure quintiles (MET.hr/wk) ● Usual walking pace (km/hr) ● Walking (W) & vPA (V) (MET.hr/wk)

Coronary events (non fatal MI or death from coronary disease) 8 years Age, study period, smoking, alcohol, BMI, menopausal status, HRT, aspirin, multivitamin, vitamin E, parental history of MI, diabetes history hypertension, hypocholesterolemia

Nakayama et al. (1997)13

Shibata Study (Japan) N ⫽ 1,341 ⱖ40 years of age 40 – 49 years of age (n ⫽ 417) 50 –99 years of age (n ⫽ 398) 60 – 69 years of age (n ⫽ 309) ⱖ70 years of age (n ⫽ 217) Leisure World Cohort Study (U.S.) N ⫽ 8532 44 –101 years of age Median ⫽ 74 years of age

Questionnaire: 1977 Measure ● Total PA energy expenditure: heavy, moderate, light (categories stated as consistent with national guidelines)

Stroke 15.5 years Age, BP, BMI, ECG, smoking amount, alcohol, history IHD, CVD health

Questionnaire: 1981 or 1983 or 1985 Measure ● Exercise (hr/day)

Stroke 13–17 years

Paganini-Hill & Barreto (2001)14

411.e6

American Journal of Preventive Medicine, Volume 33, Number 5

Exercise (hr/day) ⬍0.5 1.00 1 0.88 ⬎1.0 0.83 p trend ⬍ 0.05 (no confidence intervals provided)

Appendix A-1. continued

Reference

Study/location, number & age of women

Rockhill et al. (2001)15

Nurses’ Health Study (U.S.) N ⫽ 80,348 30 –55 years of age in 1976

Sesso et al. (1999)16

Pennsylvania Alumni Study (U.S.) N ⫽ 1,564 Mean age 45.5 years

Weller & Corey (1998)17

Canada Fitness Survey (Canada) N ⫽ 6,620 ⬎30 years of age in 1981

Outcome, follow-up period, adjustments

Summary of results (95% confidence interval)

Questionnaire ● 1980: Average hr/wk in PA (included gardening, walking, housework) during last year ● 1982: Average hr/wk in strenuous PA ● 1986, 1988, 1992: Average hr/wk in previous year doing walking/hiking, jogging, running, bicycling, swimming, racket sports, aerobics ● Usual walking pace Measure ● Total PA (hr/wk) Questionnaire: 1962 ● Daily number of flights of stairs climbed, blocks walked and sports played Measure ● Total PA energy expenditure (kcal/wk) ● Flights of stairs climbed (number/day) ● Blocks walked (number/day) ● Sports energy expenditure (kcal/wk)

Cardiovascular disease mortality 14 years Age, smoking, alcohol, height, BMI, post menopausal hormone use

Total PA (hr/wk) ⬍1 1–1.9 2–3.9 4 – 6.9 ⱖ7 p trend ⫽⬍ 0.001

Cardiovascular disease 31 years Age, BMI, hypertension, diabetes, smoking, family history CHD

Questionnaire: 1980 ● Type, frequency, duration, intensity of PA during previous year (includes household chores) Measure ● Total PA energy expenditure quartiles (kcal/kg/day) ● Leisure PA energy expenditure quartiles (kcal/kg/day) ● Non-leisure energy expenditure (household chores) quartiles (kcal/kg/day) ● Leisure PA level: sedentary (⬍3 hr/wk for ⬍9 months), moderate (ⱖ3 hr/wk ⱕ9 months or ⬍3 hr/wk for ⱖ9 months), high (ⱖ3 hr/wk for ⱖ9 months)

Cardiovascular mortality 7 years Age (adjustment for marital status, education, income, self reported health, tobacco use did not alter results)

Total PA (kcal/wk), all women ⬍500 1.00 500–999 0.99 (0.69–1.41) ⱖ1000 0.88 (0.62–1.25) p trend ⫽ 0.45 Total PA (kcal/wk), Age ⬍45 years, ⬍500 1.00 500–999 1.57 (0.79–3.10) ⱖ1000 0.94 (0.47–1.86) p trend ⫽ 0.57 Total PA (kcal/wk), Age ⬎45 years, ⬍500 1.00 500–999 0.83 (0.54–1.27) ⱖ1000 0.88 (0.58–1.33) p trend ⫽ 0.62 Stairs climbed (number/day) ⬍4 1.00 4–11 0.86 (0.60–1.23) ⱖ12 1.01 (0.69–1.47) p trend ⫽ 0.89 Blocks walked (number/day) ⬍4 1.00 4–9 0.84 (0.59–1.19) ⱖ10 0.67 (0.45–1.01) p trend ⫽ 0.054 Sports (kcal/wk) 0 1.00 1–999 1.23 (0.74–2.03) ⬎1000 1.32 (0.74–2.37) p trend ⫽ 0.33 Total PA (kcal/kg/day) 0–3.9 1.00 ⬎3.9–7.0 1.01 (0.68–1.51) ⬎7.0–11.3 0.70 (0.44–1.11) ⬎11.3 0.51 (0.28–0.91) Leisure PA (kcal/kg/day) 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 (0.50–1.26) Non-leisure 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 (0.28–0.86) Leisure PA level Sedentary 1.00 Moderate 0.90 (0.56–1.45) High 0.78 (0.52–1.15)

Physical activity measurement

1.00 0.80 (0.68 – 0.96) 0.74 (0.62– 0.88) 0.62 (0.50 – 0.77) 0.69 (0.49 – 0.97)

BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; CHD, coronary heart disease; CHF, coronary heart failure; ECG, electrocardiogram; HDL-C, HDL cholesterol; HR, hazard ratio; hr, hour; HRT, hormone replacement therapy; IHD, ischemic heart disease; kcal, kilocalories; kg, kilogram; km, kilometers; m, miles; MET, metabolic equivalent; MI, myocardial infarction; mins, minutes; mPA, moderate-intensity physical activity; PA, physical activity; SBP, systolic blood pressure; T-C, total cholesterol; vPA, vigorous-intensity physical activity; wk, week.

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Appendix A-2. Population-based studies of the association between physical activity and diabetes

Reference

Study/location, number & age of women

Dotevall et al. (2004)18

Goteborg BEDA Study of CVD (Sweden) N ⫽ 1351 39 – 65 years of age

Folsom et al. (2000)19

Iowa Women’s Health Study (U.S.) N ⫽ 34,257 55– 69 years of age

Haapanen, et al. (1997)5

Census (Finland) N ⫽ 1500 35– 63 years of age in 1980

411.e8

Physical activity measurement Questionnaire: 1979-1981 ● PA at work and leisure (including walking, gardening) Measure ● PA level: sedentary, not sedentary (mPA ⱕ4 hr/wk OR regular, strenuous or very strenuous PA) Questionnaire: 1986 ● Daily PA (not done at home or at work) to keep fit ● Frequency in moderate PA (including gardening, walking) or vigorous PA ● Participation in regular leisure PA (undefined) ● Moderate PA frequency ● Vigorous PA frequency Measure ● PA index: low (vPA or mPA rarely or a few x/ month), medium (vPA 1 x/wk OR mPA 1– 4 x/wk), high (vPA ⱖ2 x/wk OR mPA ⱖ4 x/wk)

Questionnaire: 1980 ● Frequency and duration of exercise, sports, physical recreation ● Leisure time and household chores ● Commuting to and from work Measure ● PA energy expenditure (kcal/wk) ● Vigorous PA (frequency/wk)

Follow-up period, adjustments

Summary of results (95% confidence interval)

16 –19 years Age, smoking, menopause, BMI, SBP, cholesterol, triglycerides

PA level Not sedentary Sedentary p trend ⫽ 0.071

12 years Age, education, smoking, alcohol, estrogen, diet, family history of diabetes, BMI, waist-hip ratio

Regular PA No 1.00 Yes 0.86 (0.78–0.95) mPA (frequency) rarely/never 1.00 1x/wk, few/ 0.90 (0.79–1.01) mo 2–4 x/wk 0.86 (0.76–0.98) ⬎4 x/wk 0.73 (0.62–0.85) p trend ⬍ 0.001 vPA (frequency) rarely/never 1.00 1x/wk, few/ 0.92 (0.76–1.10) mo 2–4 x/wk 0.88 (0.70–1.11) ⬎4x/wk 0.64 (0.41–1.01) p trend ⬍ 0.05 PA index, all women Low 1.00 Medium 0.91 (0.82–1.02) High 0.79 (0.70–0.90) p trend ⬍ 0.001 PA index, age 55–59 years Low 1.00 Medium 0.76 (0.62–0.92) High 0.62 (0.50–0.78) p trend ⬍ 0.001 PA index, age 60–64 years Low 1.00 Medium 0.73 (0.60–0.88) High 0.58 (0.47–0.71) p trend ⬍0.001 PA index, age 65–69 years, Low 1.00 Medium 0.76 (0.62–0.93) High 0.54 (0.43–0.68) p trend ⬍ 0.001 Total PA (kcal/wk) 0–900 1.00 901–1500 1.17 (0.50–2.70) ⬎1500 2.64 (1.28–5.44) p trend ⫽ 0.006 vPA (frequency/wk) ⱖ1 1.00 ⬍1 2.23 (0.90–5.23) p trend ⫽ 0.043

10 years Age

American Journal of Preventive Medicine, Volume 33, Number 5

1.00 1.56 (0.96 –2.53)

Appendix A-2. continued

Reference Hsia et al. (2005)20

Study/location, number & age of women Women’s Health Initiative Observational Study (U.S.) N ⫽ 86,708 Caucasian (n ⫽ 74,240) Average age: 64 years African American (n ⫽ 6465) Average age: 62 years Hispanic (n ⫽ 3231) Average age: 60 years Asian/Pacific Islander (n ⫽ 2445) Average age: 64 years American Indian (n ⫽ 327) Average age: 62 years

Physical activity measurement Questionnaire: 1994-98 ● Frequency and duration of four walking speeds, strenuous exercise, moderate exercise, light exercise Measure ● Total PA energy expenditure (METS.hr/wk) ● Walking energy expenditure (METS.hr/wk)

Follow-up period, adjustments

Summary of results (95% confidence interval)

4 – 8 years Average 5.1 years Age, BMI, alcohol use, education, smoking, hypertension, hypercholesterolemia, dietary fiber, carbohydrate energy

Walking (METS.hr/wk), combined groups 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) 10.1–40.8 0.82 (0.70–0.95) p trend ⫽ 0.009 Walking (METS.hr/wk), Caucasian group 0 1.00 0.5–2.5 0.85 (0.74–0.98) 2.6–5.0 0.87 (0.75–1.01) 5.1–10.0 0.75 (0.64–0.89) 10.1–40.8 0.74 (0.62–0.89) p trend ⬍ 0.001 Walking (METS.hr/wk), African American group 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) 10.1–40.8 0.84 (0.59–1.21) p trend ⫽ 0.478 Walking (METS.hr/wk), Hispanic group 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) 10.1–40.8 0.91 (0.51–1.62) p trend ⫽ 0.644 Walking (METS.hr/wk), Asian/ Pacific Islander group 0 1.00 0.5–2.5 0.66 (0.30–1.44) 2.6–5.0 1.02 (0.51–2.05) 5.1–10.0 0.87 (0.41–1.85) 10.1–40.8 1.53 (0.79–2.97) p trend ⫽ 0.115 Total PA (METS.hr/wk), Combined groups 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) 14.0–23.4 0.86 (0.75–0.99) 23.5–143.0 0.78 (0.67–0.91) p trend ⫽ 0.002 Total PA (METS.hr/wk), Caucasian group 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) 14.0–23.4 0.80 (0.68–0.94) 23.5–143.0 0.67 (0.56–0.81) p trend ⫽ 0.002 Total PA (METS.hr/wk), African American group 0–2.3 1.00 2.3–7.4 0.90 (0.64–1.26) 7.5–13.9 0.84 (0.61–1.18) 14.0–23.4 0.77 (0.54–1.10) 23.5–143.0 0.95 (0.66–1.37) p trend ⫽ 0.150

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Appendix A-2. continued

Reference

Hu et al. (2003)21

Study/location, number & age of women

Nurses’ Health Study (U.S.) N ⫽ 68,497 40 – 65 years of age

Physical activity measurement

Questionnaire: 1992 ● Average weekly time sitting while watching TV, at work, at home, away from home, driving ● Time spent standing or walking around at home, at work Questionnaire: 1992, 1994, 1996 ● Average time/wk walking, jogging, running, cycling, aerobics, lap swimming, racket sports ● Usual walking pace Measure ● Sitting watching television (hr/wk) ● Sitting at work, away from home, driving (hr/wk) ● Sitting at home (not TV) (hr/wk) ● Standing or walking around home (hr/wk) ● Standing/walking around at work (hr/wk) ● Combined PA and TV categories: most active (highest tertile for PA MET ⫹ TV ⬍6 hr/wk); most sedentary (ⱖ20 hr/ wk TV ⫹ least METS.hr/ wk)

Follow-up period, adjustments

6 years age, smoking, alcohol, BMI, menopausal status, HRT, aspirin, parental History of MI, family history of diabetes, PA, glycemic load, polyun saturated fatty acid, cereal fiber, trans fat

411.e10 American Journal of Preventive Medicine, Volume 33, Number 5

Summary of results (95% confidence interval) Total PA (METS.hr/wk), Hispanic group 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) 14.0–23.4 0.96 (0.54–1.70) 23.5–143.0 0.70 (0.36–1.37) p trend ⫽ 0.721 Total PA (METS.hr/wk), Asian/ Pacific Islander group 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) 14.0–23.4 1.06 (0.50–2.27) 23.4–143.0 1.37 (0.62–3.02) p trend ⫽ 0.986 Sitting watching television (hr/wk) 0–1 1.00 2–5 1.09 (0.85–1.39) 6–20 1.30 (1.03–1.63) 21–40 1.44 (1.12–1.85) ⬎40 1.70 (1.20–2.43) p trend⬍0.001 Sitting at work, away from home, driving (hr/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 trend ⫽ 0.005 Other sitting at home i.e., not TV (hr/wk) 0–1 1.00 2–5 0.87 (0.67–1.13) 6–20 0.98 (0.76–1.26) 21–40 0.94 (0.70–1.24) ⬎40 1.54 (1.10–2.18) p trend ⫽ 0.004 Standing/walking around home (hr/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 trend ⬍ 0.001 Standing/walking around at work (hr/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 trend ⫽ 0.86 Combined PA and TV categories Most active 1.00 Most 2.89 (2.21–3.79) sedentary

Appendix A-2. continued

Reference

Study/location, number & age of women

Physical activity measurement

Follow-up period, adjustments

Summary of results (95% confidence interval) Total PA (MET.hr/wk) 0–0.2 1.00 2.1–4.6 0.84 (0.72–0.97) 4.7–10.4 0.87 (0.75–1.02) 10.5–21.7 0.77 (0.65–0.91) ⬎21.7 0.74 (0.62–0.89) p trend ⫽ 0.002 Walking (MET.hr/wk) ⱕ0.5 1.00 0.6–2.0 0.95 (0.79–1.15) 2.1–3.8 0.80 (0.65–0.99) 3.9–9.9 0.81 (0.66–1.01) ⱖ10 0.74 (0.59–0.93) p trend ⫽ 0.01 Walking pace Easy 1.00 Normal 0.86 (0.73–1.01) Brisk/v. brisk 0.59 (0.47–0.73) p trend ⫽ 0.01 Leisure PA (MET.hr/wk) ⬍16 1.00 ⱖ16 0.74 (0.56–0.97) p ⫽ 0.03 Total PA (MET.hr/wk) ⬍16 1.00 ⱖ16 0.78 (0.60–1.02) p ⫽ 0.07

Hu et al. (1999)22

Nurses’ Health Study (U.S.) N ⫽ 70,102 40 – 65 years of age

Questionnaire: 1986, 1988, 1992 ● Average time/wk in walking, jogging, running, cycling, aerobics, lap swimming, racket sports ● Usual walking pace Measure ● Cumulative average (198692) Total PA energy expenditure quintiles (MET.hr/wk) ● Walking energy expenditure quintiles (MET.hr/wk) ● Usual walking pace (km/hr): easy (⬍3.2 km/ hr), normal (3.2– 4.8), brisk or very brisk (ⱖ4.8)

8 years Age, smoking, alcohol, BMI, menopausal status, HRT, aspirin, parental history of MI, history of diabetes, hypertension, hypocholeste rolemia

Kriska et al. (2003)23

Pima Indians (U.S.) N ⫽ 1052 15–59 years of age

13 years (average 6 years) Age, BMI

Weinstein et al. (2004)24

Women’s Health Study (U.S.) 37,878 ⱖ45 years in 1992

Interview: 1987-2000 ● PA during past year ● Frequency and duration of participation in specified types of leisure PA ● Time spent walking/cycling to work ● Hours spent sitting at work ● Physical activities done at work Measure ● Leisure PA energy expenditure (MET.hr/wk) ● Total PA energy expenditure (MET.hr/wk) Questionnaire: 1992 ● Average time in past year spent on walking/hiking, jogging, running, bicycling, aerobics, lap swimming, tennis, racket sports, low intensity exercise e.g., yoga ● Number of flights of stairs climbed daily Measure ● Meeting PA guidelines (kcal/wk) ● Total PA energy expenditure quartiles (kcal/wk) ● Walking time (hr/wk)

Average 6.6 years Age, family history diabetes, alcohol use, smoking status, hormone therapy, hypertension, high cholesterol, dietary factors, BMI, study group

Meeting PA guidelines (kcal/wk) ⱕ1000 1.00 ⬎1000 0.91 (0.80–1.03) Total PA (kcal/wk) ⬍200 1.00 200–599 0.91 (0.79–1.06) 600–1499 0.86 (0.74–1.01) ⱖ1500 0.82 (0.70–0.97) p trend ⫽ 0.01 Walking time (hr/wk) No walking 1.00 ⬍1 0.95 (0.82–1.10) 1.0–1.5 0.87 (0.73–1.02) 2.0–3.0 0.66 (0.54–0.81) ⱖ4 0.89 (0.73–1.09) p trend ⫽ 0.004

BMI, body mass index; HRT, hormone replacement therapy; hr, hour; kcal, kilocalories; kg, kilogram; km, kilometers; m, miles; MET, metabolic equivalent; MI, myocardial infarction; mins, minutes; mPA, moderate-intensity physical activity; PA, physical activity; SBP, systolic blood pressure; vPA, vigorous-intensity physical activity; wk, week.

Am J Prev Med 2007;33(5)

411.e11

Appendix A-3. Population based studies of the association between physical activity and gestational diabetes Reference

Study/location, number & age of women

Physical activity measurement

Follow-up period, adjustments

Summary of results (95% confidence interval) PA during year prior to pregnancy No PA 1.00 Any PA 0.44 (0.21–0.91) PA year prior to pregnancy (hr/wk) No PA 1.00 ⬍4.2 0.58 (0.27–1.24) ⱖ4.2 0.24 (0.10–0.64) PA year prior to pregnancy (MET.hr/wk) Nil 1.00 ⬍21.1 0.57 (0.27–1.21) ⱖ21.1 0.26 (0.10–0.65) PA during pregnancy No PA 1.00 Any PA 0.69 (0.37–1.29) PA during pregnancy (hr/wk) No PA 1.00 ⬍6.0 0.49 (0.21–1.13) ⱖ6.0 0.90 (0.45–1.80) PA during pregnancy (MET.hr/wk) Nil 1.00 ⬍28 0.71 (0.35–1.47) ⱖ28 0.67 (0.31–1.43) PA both before and during pregnancy No PA 1.00 PA last year only 0.40 (0.15–1.07) PA last week only 0.59 (0.16–2.14) PA both periods 0.31 (0.12–0.79) PA

Dempsey et al. (2004)25

OMEGA Study (U.S.) N ⫽ 909 18 –35 years of age (n ⫽ 659) ⱖ35 years of age (n ⫽ 250)

Interview: 1996-2000 ● Type, frequency and duration of recreational PA done in year prior to pregnancy ● Type, frequency and duration of recreational PA done in prior week Measure Using median values as cutoffs ● Average PA in year before pregnancy (hr/wk) ● Average PA energy expenditure year before pregnancy (MET.hr/wk) ● PA time during pregnancy (hr/wk) ● Average PA energy expenditure during pregnancy (MET.hr/wk)

7–9 months age, race, parity, prepregnancy BMI

Dye et al. (1997)26

U.S. N ⫽ 12,290

Interview: 1995-96 Measure ● Average frequency/wk of exercise for ⱖ30 mins during pregnancy

9 months Age, race, parity, prepregnancy BMI, gestational weight gain, insurance coverage 5 years Age, family history of diabetes, pregravid BMI, ethnicity, parity

Solomon et al. (1997)27

Nurses’ Health Study (U.S.) N ⫽ 14,613 25– 42 years of age in 1989

Questionnaire: 1989 ● (pregravid) Frequency and duration of walking, jogging, running, bicycling, calisthenics/aerobics, lap swimming, other aerobic recreation ● (pregravid) Flights of stairs climbed daily ● (pregravid) Usual walking pace Measure ● Total pregravid PA energy expenditure (METs/wk) ● Pregravid vigorous PA frequency (x/wk) ● Usual pregravid walking pace (km/hr)

Any exercise

1.00

No exercise

1.00 (0.8–1.3)

Pregravid PA (METs/wk) ⬍4 1.00 4–9.9 1.23 (0.97–1.56) 10–19.9 0.99 (0.77–1.27) 20–39.9 0.97 (0.76–1.25) ⬎40 0.98 (0.75–1.28) p trend ⫽ 0.26 Pregravid walking pace (km/hr) ⬍3.2 1.00 3.2–4.7 0.97 (0.75–1.26) 4.8–6.3 0.85 (0.64–1.12) ⱖ6.4 0.85 (0.55–1.31) p trend ⫽ 0.12 Pregravid vPA (frequency/wk) ⬍1 1.00 1–3 0.99 (0.63–1.34) ⬎4 0.78 (0.47–1.26) p trend ⫽ 0.63

BMI, body mass index; hr, hour; km, kilometer; MET, metabolic equivalent; mins, minutes; mPA, moderate-intensity physical activity; PA, physical activity; vPA, vigorous-intensity physical activity; wk, week.

411.e12 American Journal of Preventive Medicine, Volume 33, Number 5

Appendix A-4. Population based studies of the association between physical activity and breast cancer

Reference

Study/location, number & age of women

Physical activity measurement

Follow-up period, adjustments

Summary of results (95% confidence interval) PA level, all women Consistently low 1.00 Moderate/inconsistent 0.92 (0.62–1.38) Consistently high 0.58 (0.31–1.07) p trend ⫽ 0.107 PA level, women aged ⬍50 years Consistently low 1.00 Moderate/inconsistent 1.07 (0.46–2.51) Consistently high 1.19 (0.43–3.30) p trend ⫽ 0.732 PA level, women aged ⱖ50 years Consistently low 1.00 Moderate/inconsistent 0.87 (0.55–1.38) Consistently high 0.33 (0.14–0.82) p trend ⫽ 0.026 PA (kj/wk), all women ⬍840 1.00 840–2519 1.04 (0.77–1.40) 2520–6299 0.86 (0.64–1.17) ⱖ6300 0.80 (0.58–1.12) p trend ⫽ 0.11 vPA (kj/wk), all women none 1.00 1–839 1.02 (0.70–1.48) 840–2099 1.11 (0.78–1.58) 2100–4199 0.97 (0.66–1.44) ⱖ4200 0.98 (0.69–1.40) p trend ⫽ 0.9 PA (kj/wk), post menopausal women ⬍840 1.00 840–2519 0.97 (0.68–1.39) 2520–6299 0.78 (0.54–1.12) ⬎6300 0.67 (0.44–1.02) p trend ⫽ 0.03 vPA (kj/wk), post menopausal women none 1.00 1–839 0.93 (0.57–1.50) 840–2099 0.91 (0.57–1.47) 2100–4199 0.93 (0.57–1.50) ⬎4200 0.76 (0.47–1.24) p trend ⫽ 0.29

Breslow et al. (2001)28

Epidemiological Follow up Study (NHEFS) of the First National Health and Nutrition Examination Survey (U.S.) N ⫽ 6,160 24 –75 years of age in 1971-1975

Interview: 1971-1975, 1982-1984 ● Self-rating of recreation exercise amount: much, moderate, little or no exercise Measure ● Combination of PA level at 1971-1975 and 1982-1984: Consistently low (low at both times), consistently high (high at both times or moderate at one time and high at the other), moderate/inconsistent (all others)

10 years BMI, adult weight change, adult weight gain, education, age at menarche, parity, menstrual status, family history breast cancer

Lee et al. (2001)29

Women’s Health Study (U.S.) N ⫽ 39,322 ⱖ45 years of age

Questionnaire: 1992-95 ● Average weekly time over past year spent walking/ hiking, jogging, running, cycling, aerobics, low intensity exercise, racket sports, swimming ● Usual walking pace ● Number of flights of stairs climbed daily Measure ● PA energy expenditure quartiles (kj/wk) ● Vigorous PA energy expenditure (kj/wk)

Average 2 years BMI, alcohol, menarche age, age at first pregnancy lasting ⱖ6 mo, number of pregnancies lasting ⱖ6 mo, oral contraceptive, post menopausal hormones, family history of breast cancer

Am J Prev Med 2007;33(5)

411.e13

Appendix A-4. continued

Reference Luoto et al. (2000)30

Study/location, number & age of women Finnish Adult Health Behaviour Survey (Finland) N ⫽ 30,548 15– 64 years of age

Physical activity measurement Questionnaire: annually 1978–93 (not 1985) ● Frequency of leisure exercise for ⬎30 mins ● Minutes walking/cycling commuting to work Measure ● Leisure PA frequency/wk ● Commuting PA ● PA level (LTPA and commuting PA)

Follow-up period, adjustments

Summary of results (95% confidence interval)

ⱕ16 years Education, parity and age at first birth, BMI

Leisure PA (x/wk), all women ⬍1 1.00 1 0.80 (0.58–1.10) 2–3 0.92 (0.78–1.22) Daily 1.01 (0.72–1.42) Commuting PA, all women No work/at home 1.00 No PA, car 0.94 (0.66–1.34) ⬍30 mins/day 0.89 (0.67–1.18) ⱖ30 mins/day 0.87 (0.62–1.24) PA level (LTPA and commuting PA) Most active 1.00 Least active 1.01 (0.80–1.29) Leisure PA (x/wk), aged ⬍50 years ⬍1 1.00 1 0.98 (0.61–1.58) 2–3 0.92 (0.58–1.44) Daily 1.25 (0.70–1.22) Commuting PA, aged ⬍50 years No work/at home 1.00 No PA, car 1.11 (0.66–1.89) ⬍30 mins/day 1.07 (0.60–1.68) ⱖ30 mins/day 0.72 (0.38–1.36) Leisure PA (x/wk), aged ⱖ50 years ⬍1 1.00 1 0.71 (0.46–1.10) 2–3 0.96 (0.68–1.36) Daily 0.97 (0.65–1.44) Commuting PA, aged ⱖ50 years No work/at home 1.00 No PA, car 0.88 (0.55–1.39) ⬍30 mins/day 0.84 (0.60–1.16) ⬎30 mins/day 1.10 (0.69–1.50)

411.e14 American Journal of Preventive Medicine, Volume 33, Number 5

Appendix A-4. continued

Reference

Study/location, number & age of women

Physical activity measurement

Follow-up period, adjustments

Summary of results (95% confidence interval) vPA ⱖ3x/wk at 18 years of age no 1.00 yes 0.94 (0.85–1.04) p ⫽ 0.21 vPA ⱖ3x/wk at 35 years of age no 1.00 yes 0.86 (0.78–0.95) p ⫽ 0.003 vPA ⱖ3x/wk at 50 years of age no 1.00 yes 0.92 (0.83–1.01) p⫽0.08 Total PA (MET.hr/wk) None 1.00 ⬍5 0.90 (0.77–1.07) 5.1–10 0.82 (0.68–0.97) 10.1–20 0.89 (0.76–1.00) 21.1–40 0.83 (0.70–0.98) ⬎40 0.78 (0.62–1.00) p trend ⫽ 0.03 mPA ⫹ vPA (hr/wk) none 1.00 ⬍1 0.92 (0.78–1.10) 1.1–2 0.91 (0.79–1.10) 2.1–3 0.94 (0.81–1.10) 3.1–4 0.99 (0.83–1.20) 4.1–7 0.91 (0.78–1.10) ⬎7 0.79 (0.63–0.99) p trend ⫽ 0.12 vPA (hr/wk) none 1.00 ⱕ1 0.94 (0.80–1.10) 1.1–2 0.95 (0.80–1.10) 2.1–4 0.93 (0.78–1.10) ⬎4 0.91 (0.67–1.20) p trend ⫽ 0.25 PA level Low 1.00 Medium 1.12 (0.99–1.28) High 0.95 (0.83–1.10) Any regular PA No 1.00 Yes 0.99 (0.89–1.11) mPA frequency rarely/never 1.00 few x/month 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) vPA frequency rarely/never 1.00 few x/month 1.25 (1.04–1.50) 2–4 x/wk 1.14 (0.92–1.43) ⬎4 x/wk 1.05 (0.72–1.52)

McTiernan et al. (2003)31

Women’s Health Initiative Observational Study (U.S.) N ⫽ 74,171 50 –79 years of age in 1993

Questionnaire: 1993-8 ● Occurrence of strenuous PA ⱖ3x wk at age 18, 35, 50 years ● Frequency, duration and speed of walking outside the home ● Current frequency, duration of strenuous exercise, moderate exercise, low intensity exercise ● Vigorous PA ⱖ3x/wk at age 18 years, 35 years, 50 years Measure ● Total PA energy expenditure (MET.hr/wk) ● Moderate PA ⫹ vigorous PA time (hr/wk) ● Vigorous PA time (hr/wk)

Approx 6 years Mean 4.7 years 1993-1998 Age, BMI, HRT, race, geographic region, income, education, ever breastfed, hysterectomy status, family history breast cancer, smoking, parity, age at first birth, mammogram frequency, alcohol, menarche age, menopause age

Moore et al. (2000)32

Iowa Women’s Health Study (U.S.) N ⫽ 37,105 55– 69 years of age in 1986

Questionnaire: 1986 ● Any regular PA to keep fit ● Frequency of moderate PA (including gardening and walking) ● Frequency of vigorous PA Measure ● PA level: low (vPA ⬍1x/wk OR mPA ⬍1 x/wk), medium (vPA 1x/wk OR mPA 1– 4x/wk), high (vPA ⱖ2x/wk OR mPA ⱖ4x/wk) ● Any regular PA ● Moderate PA frequency ● Vigorous PA frequency

9 years Age, age at menopause, age at first live birth, BMI at age 18 years, education, family history of breast cancer, estrogen, waist to hip ratio, BMI, BMI squared

Am J Prev Med 2007;33(5)

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Appendix A-4. continued

Reference

Study/location, number & age of women

Rockhill et al. (1998)33

Nurses’ Health Study (U.S.) N ⫽ 104,468 25– 42 years of age in 1989

Rockhill et al. (1999)34

Nurses’ Health Study (U.S.) N ⫽ 85,364 (1980 data) N ⫽ 77,024 (1986 data) 30 –55 years of age in 1976

Sesso et al. (1998)35

Pennsylvania College Alumni Health Study (US) N ⫽ 1566 37– 69 years of age Mean age 45.5 years

Physical activity measurement Questionnaire: 1989 ● Months/year do strenuous PA for ⱖ2/wk while in high school and when aged 18 –22 years ● Average time/wk in past year walking/hiking, jogging, running, bicycling, lap swimming, racket sports, aerobics, rowing machine, other aerobic PA (eg lawn mowing) ● Usual walking pace Measure ● Vigorous PA frequency during high school and ages 18 –22 years (months/year) ● Moderate PA ⫹ vigorous PA ⫹ brisk walking (hr/wk) Questionnaire ● 1980: Average hr/wk in recreational moderate and vigorous PA including gardening, vigorous sports, jogging, brisk walking, bicycling, heavy housework ● 1982: average hr/wk of strenuous PA ● 1986, 1988, 1992, 1994: average time/year in walking/hiking, jogging, running, cycling, lap swimming, tennis/squash, aerobics, rowing machine ● 1986, 1988, 1992, 1994: usual walking pace (excluded if not brisk) Measure ● Cumulative average of vigorous PA or moderate PA updated every 2 years 1980 –1994 (hr/wk) ● Vigorous PA or moderate PA at 1980 baseline (hr/wk) ● Cumulative average vigorous PA 1986-1994 (hr/wk) Questionnaire: 1962 ● Number of flights of stairs climbed daily ● Number of city blocks walked daily ● Hr/wk in sports Measure ● Total PA energy expenditure tertiles (kcal/wk)

Follow-up period, adjustments

Summary of results (95% confidence interval)

6 years Baseline age, menarche age, history of benign breast disease, family History breast cancer, alcohol, height, oral contraceptive, parity and age of first birth

vPA frequency during high school and at age 18–22 years (months/year) never 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 ⫹ vPA ⫹ walking (hr/wk) ⬍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) ⱖ7 1.1 (0.8–1.5)

16 years Baseline age, menarche age, history benign breast disease, family history breast cancer, height, parity and age first birth, BMI at 18yrs, menopausal status, postmenopausal hormone use

Cumulative average vPA or mPA (hr/wk) ⱕ1.0 1.00 1.0–1.9 0.88 (0.79–0.98) 2.0–3.9 0.89 (0.81–0.99) 4.0–6.0 0.85 (0.77–0.94) ⱖ7.0 0.82 (0.70–0.97) p trend ⫽ 0.004 vPA or mPA at 1980 (hr/wk) ⱕ1 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) ⱖ7.0 0.89 (0.80–0.98) p trend ⫽ 0.004 vPA 1986-1994 (hr/wk) ⱕ1.0 1.00 1.0–1.9 0.95 (0.83–1.09) 2.0–3.9 0.85 (0.71–1.03) 4.0–6.0 0.90 (0.70–1.16) ⱖ7.0 0.87 (0.71–1.06) p trend ⫽ 0.11

31 years Age, BMI

Total PA (kcal/wk), all women ⬍500 1.00 500–999 0.92 (0.58–1.45) ⱖ1000 0.73 (0.46–1.14) p trend ⫽ 0.17 Total PA (kcal/wk), ⬍55 years of age ⬍500 1.00 500–999 0.81 (0.27–2.47) ⱖ1000 1.83 (0.77–4.31) p trend ⫽ 0.41 Total PA (kcal/wk), ⬎55 years of age (kcal/wk) ⬍500 1.00 500–999 0.95 (0.58–1.57) ⱖ1000 0.49 (0.28–0.86) p trend ⫽ 0.015

411.e16 American Journal of Preventive Medicine, Volume 33, Number 5

Appendix A-4. continued

Reference Tehard et al. (2006)36

Study/location, number & age of women E3N Study (France) N ⫽ 90,059 40 – 65 years of age in 1990

Physical activity measurement Questionnaire: 1990-1 ● Usual distance walked daily ● Average number of flights of stairs climbed daily ● Average time/wk light household PA, heavy household PA ● Average time/wk moderate recreational PA, vigorous recreational PA ● Usual distance walked (meters/day) ● Average stairs climbed (number/day) Measure ● Light household PA (hr/wk) ● Heavy household PA (hr/wk) ● Moderate PA (hr/wk) ● Vigorous PA (hr/wk) ● Total recreational PA (includes walking) (MET.hr/wk) ● Total PA (recreation ⫹ walking ⫹ stairs ⫹ household) (MET.hr/wk)

Follow-up period, adjustments

Summary of results (95% confidence interval)

12 years BMI, menopausal status, hormone replacement therapy, age at menarche, age at first full term pregnancy, parity, marital status, use of oral contraceptives, family history of breast cancer, personal history of benign breast disease employment

Walking (m/day) ⬍500 1.00 500–2000 1.03 (0.95–1.11) ⱖ2000 0.91 (0.81–1.02) p trend ⫽ 0.45 Stairs climbed (number/day) 0 1.00 1–4 0.99 (0.90–1.08) ⱖ5 1.00 (0.90–1.12) p trend ⫽ 0.84 Light household PA (hr/wk) 0 1.00 1–4 1.02 (0.82–1.28) 5–13 0.95 (0.75–1.20) ⱖ14 0.82 (0.61–1.11) p trend ⬍ 0.05 Heavy household PA (hr/wk) inactive 1.00 1–2 0.98 (0.89–1.07) 3–4 0.94 (0.84–1.06) ⱖ5 0.97 (0.81–1.15) p trend ⫽ 0.47 mPA (hr/wk) inactive 1.00 0 0.80 (0.60–1.05) 1–4 0.87 (0.79–0.94) 5–13 0.86 (0.74–0.99) ⱖ14 0.89 (0.65–1.24) p trend ⬍ 0.01 vPA (hr/wk) inactive 1.00 0 0.90 (0.81–0.99) 1–2 0.88 (0.79–0.97) 3–4 0.82 (0.71–0.95) ⱖ5 0.62 (0.49–0.78) p trend ⬍ 0.0001 Total recreational PA (MET.hr/wk) inactive 1.00 ⬍16 0.82 (0.71–0.93) 16–22.3 0.94 (0.84–1.06) 22.3–33.8 0.88 (0.79–0.98) ⱖ33.8 0.81 (0.72–0.92) p trend ⬍ 0.01 Total PA (MET.hr/wk) ⬍28.3 1.00 28.3–41.8 1.05 (0.93–1.17) 41.8–57.8 0.94 (0.83–1.05) ⱖ57.8 0.90 (0.80–1.02) p trend ⬍ 0.05

Am J Prev Med 2007;33(5)

411.e17

Appendix A-4. continued

Reference Thune et al. (1997)37

Study/location, number & age of women National Health Screening Service (Norway) N ⫽ 25,624 20 –54 years of age in 1974-1978

Physical activity measurement Questionnaire: 1974-78, 1977-83 ● Level of PA during leisure time during previous year ● Level of occupational activity during previous year Measure ● Leisure PA level (both surveys): sedentary, moderate (ⱕ4 hr/wk walking, cycling, doing PA), regular exercise (ⱕ4 hr/wk exercising for fitness or recreational athletics OR regular vigorous training or competitive sports several times/wk). ● Occupational PA (1st survey): sedentary, walking, lifting and walking, heavy manual labor ● Leisure PA (both surveys): consistently sedentary (sedentary both times), consistently active (moderate or regular time 1 & regular time 2), moderately active (all others)

Follow-up period, adjustments

Summary of results (95% confidence interval)

1994 Median follow up of 13.7 years Age, BMI, height, parity, county of residence, number of children

Leisure PA level (1st survey) Sedentary 1.00 Moderate 0.93 (0.71–1.22) Regular exercise 0.63 (0.42–0.95) p trend ⫽ 0.04 Occupational PA (1st survey) Sedentary 1.00 Walking 0.84 (0.63–1.12) Lifting & walking 0.74 (0.52–1.06) Heavy labour 0.48 (0.25–0.92) p trend ⫽ 0.02 Leisure PA level (1st survey), premenopausal women Sedentary 1.00 Moderate 0.77 (0.46–1.27) Regular exercise 0.53 (0.25–1.14) p trend ⫽ 0.10 Leisure PA level (1st survey), occupational PA (1st survey) Sedentary 1.00 Walking 0.82 (0.50–1.34) Lifting & walking 0.48 (0.24–0.95) p trend ⫽ 0.03 Leisure PA (1st survey), post menopausal women Sedentary 1.00 Moderate 1.00 (0.72–1.39) Regular exercise 0.67 (0.41–1.10) p trend ⫽ 0.15 Leisure PA (1st survey), occupational PA (1st survey) Sedentary 1.00 Moderate 0.87 (0.61–1.24) Regular exercise 0.78 (0.52–1.18) p trend ⫽ 0.24 Leisure PA (comparing surveys) consistently sedentary 1.00 moderately active 0.90 (0.61–1.32) consistently active 0.67 (0.40–1.10) p trend ⫽ 0.09

BMI, body mass index; hr, hour; HRT, hormone replacement therapy; kcal, kilocalories; kj, kilojoules; kg, kilogram; km, kilometers; m, miles; MET, metabolic equivalent; mins, minutes; mPA, moderate-intensity physical activity; PA, physical activity; vPA, vigorous-intensity physical activity; wk, week.

411.e18 American Journal of Preventive Medicine, Volume 33, Number 5

Appendix A-5. Population-based studies of the association between physical activity and colorectal cancer Reference Chao et al. (2004)38

Study/location, number & age of women

Outcome follow-up Physical activity measurement period, adjustments

Summary of results (95% confidence interval)

Cancer Prevention Study II Nutrition Cohort (U.S.) N ⫽ 80,771 50 –74 years of age in 1992 Median age 63 years

Questionnaire (1992-3) ● Average hr/wk in previous year spent walking, jogging/running, lap swimming, racket sports, cycling, aerobics, dancing Measure ● Participation in any PA ● PA time (hr/wk) ● PA energy expenditure (MET.hr/wk) ● Walking time (hr/wk) ● Walking ⫹ other PA time (hr/wk)

Any PA No 1.00 Yes 0.98 (0.70–1.37) PA time (hr/wk) None 1.00 ⬍2 1.01 (0.70–1.44) 2–3 1.01 (0.68–1.49) 4–6 0.97 (0.66–1.43) 7 1.03 (0.65–1.65) ⱖ8 0.65 (0.39–1.11) p trend ⫽ 0.14 PA (MET.hr/wk) None 1.00 ⬎7 1.02 (0.71–1.46) 7–13 0.98 (0.65–1.47) 14–23 1.00 (0.68–1.47) 24–29 0.94 (0.60–1.48) ⱖ30 0.77 (0.48–1.24) p trend ⫽ 0.15 Walking time (hr/wk) No activity 1.00 ⬍4 1.00 (0.70–1.44) 4–6 1.08 (0.71–1.63) ⱖ7 1.18 (0.71–1.95) p trend ⫽ 0.41 Walking ⫹ other PA time (hr/wk) No activity 1.00 ⬍4 0.99 (0.67–1.47) 4–6 0.72 (0.43–1.19) ⬎7 0.59 (0.36–0.98) p trend ⫽ 0.07 PA frequency (x/wk) for incident cancer ⬍1 1.00 1–3 0.81 (0.62–1.05) ⬎3 1.12 (0.83–1.52) p ⫽ 0.85 PA index for incident cancer Lowest tertile 1.00 2nd tertile 0.95 (0.68–1.33) Highest tertile 0.81 (0.54–1.23) p ⫽ 0.34 PA frequency (x/wk) for metastatic cancer ⬍1 1.00 1–3 0.71 (0.49–1.04) ⬎3 0.95 (0.61–1.47) p ⫽ 0.47 PA index for metastatic cancer Lowest tertile 1.00 2nd tertile 0.73 (0.44–1.22) Highest tertile 0.77 (0.43–1.38) p ⫽ 0.34

Lund Nilsen & Vatten Nord-Trondelag Health (2001)39 Survey (Norway) N ⫽ 38,244 ⬎20 years of age in 1984-86

Incident colon and rectal cancer, 1997, 1999 7 years Age, education, historical PA, smoking, alcohol use, red meat, folate, fiber, multivitamins, HRT

Questionnaire Incident cancer ● How often do you exercise Metastatic cancer ● How long do you exercise 12 years (1995) ● How hard do you exercise Age, BMI, diabetes, Measure blood glucose, marital ● PA frequency (x/wk) status, education ● PA index based on frequency, intensity, and duration (tertiles) (no values)

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Appendix A-5. continued Reference Martinez et al. (1997)40

Study/location, number & age of women

Outcome follow-up Physical activity measurement period, adjustments

Summary of results (95% confidence interval)

Nurses’ Health Study (U.S.) N ⫽ 67,802 30 –55 years of age in 1976

Questionnaire (1986): leisure 6 years 1986-1992 ● Average time/wk in past Age, smoking, family year spent walking/hiking, history colorectal jogging, running, cycling, cancer, BMI, lap swimming, racket postmenopausal sports, aerobics, rowing hormone use, aspirin, machine red meat intake, Measure alcohol ● Average weekly PA (MET.hr/wk) ● Moderate intensity PA time (hr/day) ● High intensity PA (vPA) time (mins/day) ● Light intensity PA (LPA) time (hr/day)

PA (MET.hr/wk) ⬍2 1.00 2–4 0.71 (0.44–1.15) 5–10 0.78 (0.50–1.20) 11–21 0.67 (0.42–1.07) ⬎21 0.54 (0.33–0.90) p trend ⫽ 0.03 mPA time (hr/day) ⬍1 1.00 ⬎1 0.69 (0.52–0.90) vPA time (mins/day) ⬍30 1.00 ⱖ30 0.61 (0.43–0.86) LPA time (hr/day) ⬍1 1.00 ⱖ1 1.54 (0.94–2.50)

BMI, body mass index; hr, hour; HRT, hormone replacement therapy; LPA, light physical activity; MET, metabolic equivalent; mins, minutes; mPA, moderate-intensity physical activity; PA, physical activity; vPA, vigorous-intensity physical activity; wk, week.

Appendix A-6. Population-based studies of the association between physical activity and cancer (excluding breast and colorectal cancer)

Reference

Study/location, number & age of women

Outcome follow-up period, Physical activity measurement adjustments

Anderson et al. Iowa Women’s Health Questionnaire: 1986 Ovarian cancer (2004)41 Study (U.S.) ● Aside from work and 15 years N ⫽ 31,381 home, PA done on daily Age, family history of ovarian 55– 69 years of age basis to keep physically fit cancer, hysterectomy status, in 1986 ● Frequency of mPA (e.g., number live births, years bowling, golf, light sports, smoking, estrogen gardening, long walks) replacement therapy ● Frequency of vPA (e.g., jogging, racket sports, swimming, aerobics, strenuous sports) Measure ● Participation in regular PA ● PA level: low (vPA ⬍1 x/ wk OR mPA ⬍1 x/wk), medium (vPA 1x/wk OR mPA 1– 4x/wk), high (vPA ⱖ2x/wk OR mPA ⱖ4x/ wk) ● mPA frequency ● vPA frequency

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Summary of results (95% confidence interval) Regular PA No Yes p trend ⫽ 0.12 PA level (/wk) Low Medium High p trend ⫽ 0.03 mPA (/wk) rarely/never 1 2–4 ⬎4 p trend ⫽ 0.26 vPA (/wk) rarely/never 1 2–4 ⬎4 p trend ⬍ 0.01

1.00 1.24 (0.94–1.63)

1.00 1.14 (0.81–1.60) 1.42 (1.03–1.97)

1.00 0.75 (0.50–1.14) 0.98 (0.66–1.44) 1.17 (0.78–1.75)

1.00 0.84 (0.50–1.43) 1.03 (0.58–1.80) 2.38 (1.29–4.38)

Appendix A-6. continued

Reference Bertone et al. (2001)42

Study/location, number & age of women Nurses’ Health Study (U.S.) N ⫽ 92,825 30 –55 years of age in 1976

Outcome follow-up period, Physical activity measurement adjustments

Summary of results (95% confidence interval)

Questionnaire: 1980 Ovarian cancer ● Hr/weekday and 16 years hr/weekend in vigorous Age, parity, oral PA (e.g., vigorous sport, contraception, tubal brisk walking, hill ligation, menarche age, bicycling) and moderate hormone use, menopause, PA (e.g., level bicycling, smoking walking, light sport) ● Type and frequency/wk of exercise producing a sweat Questionnaire: 1986, 1988, 1992, 1994 ● Time/wk jogging, running, bicycling, lap swimming, racket sports, aerobics, walking/hiking ● Usual walking pace ● Number flights of stairs climbed daily Questionnaire: 1994 ● Time/wk lower intensity PA, e.g., yoga, stretching ● Time/wk in other vPA, e.g. mowing lawn Measure ● PA level 1980, 1986-1996, 1986, average 1980-1986 (hr/wk) ● PA level 1980 intensity and frequency: low (not sweating), mPA (⬍5METs), vPA (ⱖ5 METS) ● Total PA energy expenditure cumulative average 1986-1996 (MET.hr/wk) ● Total PA energy expenditure 1986 only (MET.hr/wk)

1980–1996 cumulative average (hr/wk) ⬍1.00 1.00 1–⬍2 0.80 (0.59–1.08) 2–⬍4 0.86 (0.65–1.15) 4–⬍7 1.10 (0.82–1.49) ⱖ7 0.80 (0.49–1.32) p ⫽ 0.59 1980 only (hr/wk) ⬍1 1.00 1–⬍2 0.75 (0.45–1.02) 2–⬍4 0.86 (0.61–1.20) 4–⬍7 1.01 (0.73–1.40) ⱖ7 0.92 (0.62–1.36) p ⫽ 0.74 1986–1996 cumulative average (hr/wk) ⬍1 1.00 1–⬍2 1.13 (0.77–1.65) 2–⬍4 1.10 (0.76–1.60) 4–⬍7 0.98 (0.64–1.50) ⱖ7 1.26 (0.80–1.97) p ⫽ 0.59 1996 only (hr/wk) ⬍1 1.00 1–⬍2 1.41 (0.94–2.11) 2–⬍4 1.23 (0.81–1.85) 4–⬍7 1.12 (0.69–1.84) ⱖ7 1.64 (1.05–2.58) p ⫽ 0.13 average 1980–1986 (hr/wk) ⬍1 1.00 1–⬍2 0.72 (0.48–1.08) 2–⬍4 1.00 (0.70–1.43) 4–⬍7 0.97 (0.64–1.45) ⱖ7 1.46 (0.82–2.60) p ⫽ 0.18 PA level 1980 (intensity and frequency) Low 1.00 mPA, ⱕ2 x/wk 0.57 (0.36–0.92) mPA, 3–4 x/wk 1.35 (0.89–2.03) mPA, ⬎4 x/wk 0.94 (0.57–1.54) p trend ⫽ 0.93 vPA, ⱕ2 x/wk 1.05 (0.68–1.63) vPA, 3–4 x/wk 1.58 (1.05–2.38) vPA, ⬎4 x/wk 1.48 (0.89–2.48) p trend ⫽ 0.03 Total PA cumulative average 1986-1996 (MET.hr/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 (0.83–2.10) 30–⬍30 1.84 (1.12–3.02) ⬎30 1.27 (0.75–2.14) p trend ⫽ 0.52 Total PA energy expenditure 1986 only (MET.hr/wk) 0–⬍2.5 1.00 2.5–⬍5 1.11 (0.75–1.66) 5–⬍10 1.30 (0.89–1.90) 10–⬍20 1.02 (0.68–1.51) 20–⬍30 1.41 (0.90–2.18) ⬎30 1.16 (0.75–1.80) p ⫽ 0.48

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Appendix A-6. continued

Reference Gregg et al. (2003)4

Kushi et al. (1997)9

Study/location, number & age of women

Outcome follow-up period, Physical activity measurement adjustments

Study of Osteoporotic Questionnaire: 1986–1988, Fractures (U.S.) 1992-1994 (median period N ⫽ 7553 5.7 years) ⱖ65 years of age ● Number city blocks or equivalent walked daily ● Frequency and duration of leisure activities, e.g., dancing, gardening, swimming, aerobics in past year ● Separated walking for exercise and other walking Measure ● Total PA energy expenditure at baseline quintiles (kcal/wk) ● Walking energy expenditure at baseline quintiles (kcal/wk) ● PA change: sedentarysedentary (⬍595 kcal/wk), sedentary/active (moved from lowest 40% to highest 60%), active/sedentary (moved from highest 60% to lowest 40%), active/ active Iowa Women’s Health Questionnaire: 1986 Study (U.S.) ● Any daily leisure time PA N ⫽ 32,763 (not occupational or 55– 69 years in 1985 domestic) to keep physically fit ● Frequency and duration of moderate PA (including gardening and walks) ● Frequency and duration of vigorous PA Measure ● Daily PA ● Moderate PA frequency ● Vigorous PA frequency ● PA level: low (vPA ⬍1x/wk or mPA ⬍1x/wk), medium (vPA 1x/wk or mPA 1– 4x/ wk), high (vPA ⱖ2x/wk or mPA ⱖ4x/wk)

Cancer mortality 12.5 years Age, smoking, BMI, stroke, diabetes, hypertension, self rated health at baseline, cancer, chronic obstructive pulmonary disease, incident hip fracture

Cancer mortality 7 years Age at baseline, age at menarche, age at menopause, age at first live birth, parity, alcohol, total energy intake, smoking, estrogen, BMI at baseline, BMI at age 18, waist to hip ratio, education, marital status, family history cancer

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Summary of results (95% confidence interval) Total PA (kcal/wk) ⬍163 163–503 504–1045 1046–1906 ⱖ1907 Walking (kcal/wk) ⬍70 70–186 187–419 420–897 ⬎898 PA change Sedentary-sedentary Sedentary-active Active-sedentary Active-active

Daily PA no yes mPA (frequency) rarely/never few/month-1x/wk 2–4 x/wk ⬎4 x/wk p trend ⫽ 0.33 vPA (frequency) rarely/never few/month-1 x/wk 2–4 x/wk ⬎4 x/wk p trend ⫽ 0.28 PA level Low Medium High p trend ⫽ 0.64

1.00 0.77 (0.60–0.97) 0.90 (0.71–1.13) 0.62 (0.48–0.81) 0.85 (0.67–1.09) 1.00 1.08 (0.85–1.36) 0.89 (0.69–1.15) 0.90 (0.70–1.16) 0.85 (0.65–1.10) 1.00 0.49 (0.29–0.84) 0.61 (0.42–0.90) 0.82 (0.58–1.16)

1.00 0.93 (0.76–1.14) 1.00 0.79 (0.60–1.03) 0.80 (0.61–1.05) 0.85 (0.63–1.15)

1.00 1.09 (0.77–1.53) 0.83 (0.52–1.33) 0.69 (0.31–1.54)

1.00 0.92 (0.72–1.16) 0.94 (0.73–1.21)

Appendix A-6. continued

Reference

Study/location, number & age of women

Outcome follow-up period, Physical activity measurement adjustments

Summary of results (95% confidence interval) Total PA (MET.hr/wk) ⱕ2.8 1.00 2.9–7.7 1.00 (0.56–1.77) 7.8–16.9 0.84 (0.46–1.55) 17.0–33.9 0.84 (0.45–1.65) ⱖ34.0 0.78 (0.42–1.47) p trend ⫽ 0.40 vPA (MET.hr/wk) 0 1.00 0.2–1.6 0.66 (0.34–1.29) 1.7–6.9 0.64 (0.31–1.35) 7.0–15.9 0.76 (0.41–1.43) ⱖ16 1.06 (0.57–1.96) p trend ⫽ 0.80 mPA (MET.hr/wk) ⬍0.9 1.00 0.9–2.6 1.01 (0.56–1.81) 2.7–4.4 0.85 (0.47–1.55) 4.5–10.7 0.85 (0.46–1.57) ⬎10.8 0.52 (0.25–1.05) p trend ⫽ 0.05 Walking/hiking (/wk) ⬍20 mins 1.00 20–80 mins 0.79 (0.48–1.30) 1.5–3.0 hr 0.65 (0.38–1.13) ⱖ4 hr 0.48 (0.24–0.97) p trend ⫽ 0.04 Occupational PA 1960 Very high/high 1.00 Medium 1.03 (0.94–1.13) Light 1.05 (0.94–1.16) Sedentary 1.13 (0.99–1.29) p trend ⫽ 0.11 Occupational PA 1970 Very high/high 1.00 Medium 1.02 (0.95–1.10) Light 1.16 (1.05–1.27) Sedentary 1.32 (1.17–1.50) p trend ⬍ 0.001 Occupational PA same in 1960 and 1970 Very high/high 1.00 Medium 1.04 (0.89–1.22) Light 1.11 (0.94–1.31) Sedentary 1.30 (1.03–1.65) p trend ⫽ 0.04 Total PA (MET.hr/wk) None 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 (0.44–1.89) ⱖ31.5 1.42 (0.59–3.41) p trend ⫽ 0.73 Total PA at 40 years of age (MET.hr/wk) None 1.00 ⬎0–7 1.15 (0.64–2.07) ⬎7–17.5 0.77 (0.41–1.46) ⬎17.5–31.5 0.77 (0.38–1.53) ⱖ31.5 0.94 (0.44–2.03) p trend ⫽ 0.38 Exercise in 1982 None/slight 1.00 Moderate 0.84 (0.54–1.29) Heavy 0.97 (0.40–2.35) p trend ⫽ 0.59

Michaud et al. (2001)43

Nurses’ Health Study (U.S.) N ⫽ 117,041 30 –55 years of age

Questionnaire: 1986 ● Average time/wk during previous year walking/hiking, jogging, running, cycling, lap swimming, racket sports, calesthenics/aerobics ● Number flights of stairs climbed daily Measure ● Total PA quintiles (MET.hr/wk) ● Moderate PA (walking, hiking, stair climbing) quintiles (MET.hr/wk) ● Vigorous PA quintiles (MET.hr/wk) ● Walking/hiking (time/wk)

Pancreatic cancer 10 –20 years Height, age group, smoking, diabetes history, cholecystectomy, protein intake, dietary fruit and vegetables, coffee, fat intake

Moradi et al. (1998)44

National Census (Sweden) N ⫽ 253,356 11–106 years of age in 1971

Census data: 1960, 1970 Endometrial cancer ● Occupational group 18 years Measure Age at follow-up, place of ● Occupational PA in 1960, residence, year of follow1970, and both 1960/70: up, socioeconomic status very high/high (cleaners, farmers, dockers), medium (maids, waiters, nurses, cooks), light (teachers, hairdressers), sedentary (book keepers, secretaries)

Patel et al. (2005)45

American Cancer Society Cancer Prevention Study II Nutrition Cohort (U.S.) N ⫽ 76,038 50 –74 years of age in 1992

Questionnaire: 1982 Pancreatic cancer ● How much exercise (work 7 years or play) Age, smoking, years since Questionnaire: 1992 quitting smoking, ● Average time/wk during education, family history last year walking, jogging/ pancreatic cancer, history running, lap swimming, gallbladder disease, history racket sports, bicycling, diabetes, total caloric aerobics, dancing intake, baseline PA (1992) ● At age 40, average time/wk during last year walking, jogging/running, lap swimming, racket sports, bicycling, aerobics, dancing Measure ● Total PA (MET.hr/wk) ● Total PA (MET.hr/wk) at age 40 years ● Past exercise amount (1982) (not quantified)

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Appendix A-6. continued

Reference Rockhill et al. (2001)15

Sinner et al. (2005)46

Terry et al. (1999)47

Study/location, number & age of women

Outcome follow-up period, Physical activity measurement adjustments

Nurses’ Health Study (U.S.) N ⫽ 80,348 30 –55 years of age in 1976

Questionnaire: 1980, 1982, 1986, 1988, 1992 ● 1980: average hr/wk during last year in PA (included sports, jogging, gardening, walking, housework) ● 1982: average hr/wk in strenuous PA ● 1982: average hr/wk in strenuous PA ● 1986 –1992: average hr/wk during previous year in each of walking/hiking, jogging, running, bicycling, swimming, racket sports, aerobics Measure ● Cumulative average PA (hr/wk) Iowa Women’s Health Questionnaire: 1986 Study (U.S.) ● Any daily leisure time PA N ⫽ 41,836 (not occupational or 55– 69 years of age domestic) to keep in 1985 physically fit ● Frequency and duration of moderate PA (including gardening and walks) ● Frequency and duration of vigorous PA Measure ● Daily PA ● Moderate PA frequency ● Vigorous PA frequency ● PA level: low (vPA ⬍1x/wk or mPA ⬍1x/wk), medium (vPA 1x/wk or mPA 1– 4x/ wk), high (vPA ⱖ2x/wk or mPA ⱖ4x/wk) Swedish Twin Registry Questionnaire: 1967 (Sweden) Measure N ⫽ 11,659 ● PA amount: (no Born 1886-1925 quantification)

Thune & Lund Norway Questionnaire: 1972-1978 (1997)48 N ⫽ 28,274 ● PA during recreational 20 – 49 years of age hours between 1972–1978 ● PA during working hours Measure ● Leisure PA: sedentary (reading, TV), moderate (walking/cycling ⱕ4 hr/ wk), regular exercise training (⬎4 hr/wk) ● Occupational PA ● Leisure ⫹ Occupational PA Tripathi et al. (2002)49

Summary of results (95% confidence interval)

Cancer mortality 14 years Age at baseline, smoking, recent alcohol, height, BMI, post menopausal hormone use

PA (hr/wk) ⬍1 1–1.9 2.0–3.9 4.0–6.9 ⬎7.0 p trend ⫽ 0.25

Pancreatic cancer 12 years Age, smoking, multivitamin

Daily PA No Yes mPA frequency rarely/never, few 1 x/wk, few x/month ⱖ 2 x/wk vPA frequency rarely/never, few 1 x/wk, few x/mo ⬎2 x/wk PA level Low Medium High PA Hardly any Light Regular Hard p trend ⫽ ⬍0.01 Occupational PA Sedentary Walking Lifting p trend ⫽ 0.03 Leisure PA Sedentary Moderate Regular p trend ⫽ 0.88 Occupational PA ⫹ Sedentary Any PA Regular PA No Yes p ⬍ 0.05 PA level Low Medium High Regular PA No Yes p ⬍ 0.05

Endometrial cancer 25 years Age, weight, parity

Lung cancer 13–19 years Age

Iowa Women’s Health Questionnaire: 1986 Bladder carcinoma Study (U.S.) ● Frequency and duration of 13 years N ⫽ 37,459 moderate PA (including Age, smoking, diabetes, BMI, 55– 69 years of age gardening and walks) alcohol, marital status, in 1986 ● Frequency and duration of occupation vigorous PA Measure ● Regular PA ● PA level: low (vPA ⬍1x/wk or mPA ⬍1x/wk), medium (vPA 1x/wk or mPA 1– 4x/ wk), high (vPA ⱖ2x/wk or mPA ⱖ4x/wk)

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1.00 0.92 (0.83–1.02) 0.85 (0.76–0.94) 0.95 (0.85–1.07) 0.87 (0.72–1.04)

1.00 1.08 (0.81–1.42) 1.00 1.06 (0.71–1.58) 1.14 (0.79–1.65) 1.00 1.02 (0.63–1.66) 0.93 (0.55–1.57) 1.00 0.88 (0.62–1.24) 1.29 (0.93–1.77) 1.00 0.5 (0.4–0.8) 0.6 (0.2–1.7) 0.1 (0.04–0.6)

1.00 0.81 (0.37–1.76) 0.79 (0.30–2.12)

1.00 0.91 (0.48–1.71) 0.99 (0.35–2.78) LTPA 1.00 0.87 (0.21–3.62) 1.00 0.59 (0.40–0.89)

1.00 0.62 (0.38–1.00) 0.73 (0.46–1.17) 1.00 0.66 (0.43–1.01)

Appendix A-6. continued

Reference van Dijk et al. (2004)50

Study/location, number & age of women Netherlands Cohort study on Diet and Cancer (Netherlands) N ⫽ 62,573 5– 69 years in 1986

Outcome follow-up period, Physical activity measurement adjustments

Summary of results (95% confidence interval)

Questionnaire: 1986 Renal cell carcinoma ● PA in previous year Average 9.3 years follow-up Measure Age, smoking, energy intake, ● Non-occupational PA BMI including leisure PA, shopping, dog walking, gardening, sports, exercise, cycling/walking, active commuting (mins/day)

PA mins/day ⬍30 30 – 60 60 –90 ⬎90 p trend ⫽ 0.55

1.00 1.13 (0.59 –2.15) 1.43 (0.73–2.79) 1.13 (0.56 –2.29)

BMI, body mass index; hr, hours; kcal, kilocalories; mins, minutes; mPA, moderate PA; PA, physical activity; vPA, vigorous-intensity physical activity; wk, week.

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