Physical Activity and Coronary Heart Disease Risk in Men : Does the Duration

of Exercise Episodes Predict Risk?

I-Min Lee, Howard D. Sesso and Ralph S. Paffenbarger, Jr
Circulation 2000;102;981-986
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 Physical Activity and Coronary Heart Disease Risk in Men
Does the Duration of Exercise Episodes Predict Risk?
I-Min Lee, MBBS, ScD; Howard D. Sesso, ScD; Ralph S. Paffenbarger, Jr, MD, DrPH

BackgroundPhysical activity is associated with a decreased risk of coronary heart disease (CHD). However, it is unclear
whether the duration of exercise episodes is important: Are accumulated shorter sessions as predictive of decreased risk
as longer sessions if the same amount of energy is expended?
Methods and ResultsIn the Harvard Alumni Health Study, we prospectively followed 7307 Harvard University alumni
(mean age 66.1 years) from 1988 through 1993. At baseline, men reported their walking, stair climbing, and
participation in sports or recreational activities. For each of the latter activities, they also reported the frequency and
average duration per episode. During follow-up, 482 men developed CHD. In age-adjusted analysis, a longer duration
of exercise episodes predicted lower CHD risk (P trend0.04). However, after total energy expended on physical
activity and potential confounders was accounted for, duration no longer had an independent effect on CHD risk (P
trend0.25); that is, longer sessions of exercise did not have a different effect on risk compared with shorter sessions,
as long as the total energy expended was similar. In contrast, higher levels of total energy expenditure significantly
predicted decreased CHD risk in both age-adjusted (P trend0.009) and multivariate (P trend0.046) analyses.
ConclusionsThese data clearly indicate that physical activity is associated with decreased CHD risk. Furthermore, they
lend some support to recent recommendations that allow for the accumulation of shorter sessions of physical activity,
as opposed to requiring 1 longer, continuous session of exercise. This may provide some impetus for those sedentary
to become more active. (Circulation. 2000;102:981-986.)
Key Words: coronary disease exercise men

P hysical activity is clearly associated with a decreased risk

of coronary heart disease.1,2 Unfortunately, most adults
are physically inactive: 60% of US adults are not physically
active on a regular basis, whereas 25% are not active at all.2
In an attempt to foster greater physical activity, the Centers
for Disease Control and Prevention and the American College
of Sports Medicine recently issued a new recommendation:
Every US adult should accumulate 30 minutes or more of
moderate-intensity physical activity on most, preferably all,
days of the week.3 This recommendation also was developed
to promote physical activity among those who do not enjoy or
are unable to participate in vigorous activity.
The new prescription makes lesser demands than previous
recommendations.4 The major differences are a concession to
moderate intensity activity (as opposed to the prior require-
ment for vigorous exercise) and an allowance for the accu-
mulation of short sessions of activity (as contrasted to the
earlier need for 1 continuous, longer session). Whether
intermittent, short sessions of activity are associated with
benefit equal to that of 1 continuous, longer session remains
controversial. The allowance for accumulated sessions of
activity was based in part on the findings from 2 experimental
studies in which investigators compared intermittent sessions
with 1 continuous session of moderate to vigorous intensity
exercise that required the same total energy expenditure.5,6 In
both studies, subjects who exercised with the exercise broken
up into intermittent sessions also experienced increases in
physical fitness and improvements in blood lipid levels.
To date, no study has examined the association between
physical activity of different durations and long-term outcomes
such as coronary heart disease. It is important to directly assess
long-term outcomes because improvements in short-term param-
eters, such as blood lipid levels, do not necessarily translate into
subsequent benefits. For example, in the Heart and Estrogen/
Progestin Replacement Study, estrogen-plus-progestin therapy
did not decrease the early incidence of subsequent coronary
events among women with coronary disease, despite significant
improvements in their lipid profile.7

Received January 11, 2000; revision received March 23, 2000; accepted March 27, 2000.
From the Department of Epidemiology (I.-M.L., H.D.S., R.S.P.), Harvard School of Public Health, Boston, Mass; Division of Preventive Medicine
(I.-M.L., H.D.S.), Department of Medicine, Brigham and Womens Hospital and Harvard Medical School, Boston, Mass; and Division of Epidemiology
(R.S.P.), Stanford University School of Medicine, Stanford, Calif.
This is report No. LXXVII in a series on chronic disease in former college students (College Alumni Health Study).
Correspondence to I-Min Lee, MBBS, ScD, Brigham and Womens Hospital, 900 Commonwealth Ave E, Boston, MA 02215. E-mail
i-min.lee@channing.harvard.edu
Reprint requests to I-Min Lee, MBBS, ScD, Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA
02115.
2000 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org

981
Downloaded from circ.ahajournals.org by on January 3, 2011
982 Circulation August 29, 2000

Therefore, we decided to investigate whether different TABLE 1. Characteristics of Subjects at Baseline, 1988
durations of an exercise episode are associated with different Characteristic
risks of coronary heart disease. We specifically wanted to
Mean age, y (SD) 66.1 (7.5)
determine whether the duration of an exercise episode pre-
dicted risk, after the total energy expended on physical Mean body mass index, kg/m2 (SD) 24.74 (2.93)
activity was accounted for. Cigarette smoking habit, %
Never smoked 37.9
Methods Past smoker 53.9
Current smoker 8.2
Study Subjects
Study subjects were from the Harvard Alumni Health Study, an Physician-diagnosed hypertension, % 27.1
ongoing study of men who matriculated as undergraduates at Physician-diagnosed diabetes mellitus, % 4.4
Harvard University between 1916 and 1950. This study was ap- Parental death at age 65 y, %
proved by the institutional review committee of the Harvard School
of Public Health. Beginning in 1962, alumni have been sent periodic Neither parent 67.4
surveys that request information on health habits and medical 1 parent 28.9
history. For the present study, the 12 805 men who responded to a Both parents 3.8
health survey in 1988 were eligible. We then excluded men who
Taking vitamin or mineral supplements, % 44.1
reported a history of cardiovascular disease or cancer (n3543)
because this would likely influence their physical activity levels, as Alcohol consumption, %
well as those with missing physical activity information on the 020 g/wk 25.8
survey (n623). Of the remaining 8639 men, we successfully
2184 g/wk 24.3
followed 7373 (85%) through 1993 (ie, they returned another health
survey in 1993 or were known to have died). We further excluded 66 85175 g/wk 25.0
men who did not provide information regarding coronary heart 175 g/wk 24.9
disease on the 1993 survey or who had died but for whom we were Red meat consumption, %
unable to obtain death certificates to determine the cause and date of
death. This left 7307 men for the present analyses. Up to 3 servings/mo 22.6
12 servings/wk 45.9
Assessment of Physical Activity 3 servings/wk 31.6
On the 1988 survey, we asked men to estimate the number of city Vegetable consumption, %
blocks walked daily and the number of flights of stairs climbed daily,
as well as to list any sports or recreational activities (up to 5) in Up to 6 servings/wk 24.1
which they had engaged during the past week.8 For each activity 12 servings/d 61.7
listed, we further inquired about the frequency and average duration 3 servings/d 14.3
per episode during the past week. This assessment of physical
Total energy expenditure, %*
activity has been shown to be reliable and valid for large population
studies.9 11 For example, for energy expenditure, the test-retest 4200 kJ/wk 29.7
correlation coefficient during 1 month was 0.72, whereas question- 42008399 kJ/wk 22.6
naire estimates compared with estimates from physical activity 840012 599 kJ/wk 17.1
records yielded a correlation coefficient of 0.65.11
We estimated the total energy expended on physical activity in the 12 60016 799 kJ/wk 10.4
following manner: walking 1 block daily required 235 kJ/wk (4.2 16 800 kJ/wk 20.2
kJ1 kcal), whereas climbing up and down 1 flight of stairs daily Engaged in vigorous sports or 43.1
required 59 kJ/wk.12 The energy expended on each sport or recre- recreational activities in past week, %
ation, in kilojoules per week, was estimated by taking into account
the energy cost of the activity,13,14 as well as the frequency and Sports or recreational activities in past week, %
duration of participation during the past week. We then summed 0 25.6
kilojoules per week for walking, stair climbing, and all sports or 1 38.2
recreation to estimate the total energy expenditure. In analyses, we
2 22.8
classified men into 1 of 5 categories of total energy expenditure
(Table 1): 4200, 4200 to 8399, 8400 to 12 599, 12 600 to 16 799, 3 11.2
and 16 800 kJ/wk. 4 1.8
We were primarily interested in the average time spent on each
5 0.3
episode of physical activity for every sport or recreational activity
reported. We hypothesized a priori that if a subject engaged in Longest episode of activity, %
different activities (of like intensity), with each having a different No sports or recreational activities 25.6
average duration per episode, maximum benefit should accrue from 115 min 4.8
the activity with the longest average duration per episode. Therefore,
for each subject, we selected the activity with the longest average 1630 min 14.5
duration per episode and classified men according to this maximum 3145 min 6.9
average duration per episode (Table 1): no sports or recreational 4660 min 12.8
activities reported, 1 to 15, 16 to 30, 31 to 45, 46 to 60, or 60
minutes. 60 min 35.4
*Estimated from walking, climbing stairs, and participation in sports or
Determination of Coronary Heart Disease recreational activities.
We sent another health survey to subjects in 1993 that included Activities that required 6 times resting metabolic rate (METs).
questions on whether a physician had ever diagnosed angina pectoris Determined from the sport or recreational activity in the past week with the
or myocardial infarction and whether the subject had ever undergone longest average duration per episode.

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TABLE 2. Relative Risks of Coronary Heart Disease, 1988 1993, According to
Duration per Episode of Physical Activity
Longest Episode of Physical
Activity, min* Adjusted for Age
No sports or recreational 1.00 (Referent)
activities
115 0.85 (0.551.31)
1630 0.76 (0.571.03)
3145 0.85 (0.581.24)
4660 0.80 (0.591.10)
60 0.78 (0.620.98)
P, trend 0.04
*Determined from the sport or recreational activity in the past week with the longest average
duration per episode.
Estimated from walking, climbing stairs, and participation in sports or recreational activities,
classified as in Table 1.
Also adjusted for cigarette smoking; hypertension; diabetes; early parental death; intake of
vitamin or mineral supplements; alcohol, red meat, and vegetable consumption; and participation in
vigorous activities (6 METs).
CABG or PTCA. For those who responded in the affirmative, we
further enquired about the year of onset or procedure. Self-reported
coronary heart disease is believed to be valid in this population.15
In addition, the Harvard Alumni Office maintains listings of
deceased alumni. Using this information, we obtained copies of
official death certificates. To determine the completeness of mortal-
ity follow-up, we searched the National Death Index, a national
compilation of decedents,16 from 1988 through 1992 for 500 ran-
domly chosen subjects who were deemed alive according to our
records. Only 2 were positively identified as dead, for a mortality
follow-up rate of 99.6%.
Using these sources, we determined whether subjects had devel-
oped coronary heart disease after the return of the 1988 health survey
through 1993. The year of occurrence was the earliest year reported
for any of the conditions given or the year of death for men noted to
have coronary heart disease as either the underlying or a contributing
cause of death on their death certificates.
Statistical Analyses
We used proportional hazards regression to estimate the relative risks
of coronary heart disease associated with the maximum average
duration (hereafter referred to as duration) per episode of sport or
recreational activity.17 There was no evidence that proportional
hazards assumptions were violated. In initial analyses, we adjusted
the relative risks for differences in age. Because longer durations of
activity yield higher energy expenditures, which are associated with
lower coronary heart disease risk,2,3 we then also adjusted for total
energy expenditure. That is, we sought to determine whether
different durations per episode of activity differentially predicted
coronary heart disease risk among subjects with the same total
energy expenditure. Next, we further controlled for differences in
these potential confounders: cigarette smoking; hypertension; diabe-
tes; early parental death; intake of vitamin or mineral supplements;
alcohol, red meat, and vegetable consumption; and participation in
vigorous activities (6 METs). In analyses, variables were catego-
rized as shown in Table 1 with the exceptions of age (in continuous
years) and body mass index (grouped in approximate fifths: 22.5,
22.5 to 23.5, 23.5 to 24.5, 24.5 to 26.0, and 26.0 kg/m2). We
calculated 95% CIs for estimated relative risks and used 2-tailed tests
of significance.
To minimize potential bias due to men who may have decreased
their activity level at baseline because of preclinical heart disease, we
conducted a separate analysis that excluded the first 2 years of
follow-up. Finally, we examined whether the association of exercise
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Lee et al Duration of Activity and CHD Risk 983
Relative Risk (95% CI)
Adjusted for Age and
Total Energy Expenditure Multivariate
1.00 (Referent) 1.00 (Referent)
0.94 (0.611.47) 1.15 (0.701.87)
0.92 (0.651.30) 1.01 (0.681.51)
1.07 (0.681.67) 1.11 (0.671.84)
1.02 (0.691.50) 1.18 (0.771.80)
1.05 (0.731.49) 1.25 (0.831.87)
0.68 0.25
duration with coronary heart disease risk varied by age, total energy
expenditure, or intensity of the sports or recreational activities in
which men engaged. We did so by including an interaction term with
exercise duration for each of these variables in 3 separate multivar-
iate models.
Results
Table 1 provides a description of the study subjects. Men
were older, with a mean age of 66.1 years at study entry. A
sizable proportion of men (35.4%) reported episodes of
activity lasting 1 hour in the past week. These men spent
their time playing tennis (24.1%), golfing (13.6%), gardening
and working in the yard (12.2%), skiing (12.0%), and
assorted activities (remainder).
When we examined the baseline characteristics of men
according to the duration of their exercise episodes, men who
did not report any sports or recreational activities had a worse
coronary profile than did those who reported any activities
(data not shown). However, there was no clear pattern across
categories of duration among men who reported at least 1
activity, with the exception of the physical activity variables.
As would be expected, with the longer duration of exercise
episodes, total energy expenditure increased, as did the
proportion of men who engaged in vigorous activities and the
number of leisure-time activities reported.
The association of duration per episode of sport or recre-
ational activity with coronary heart disease risk is shown in
Table 2. During the 5 years of follow-up (1988 to 1993), 482
men developed coronary heart disease. The number of men
who developed coronary heart disease in each of the 6
categories of exercise duration was 155, 24, 61, 32, 55, and
155, respectively. In age-adjusted analysis, there was a
significant trend (P0.04) of decreasing coronary heart
disease risk with increasing time per episode spent on sports
or recreational activities.
However, when we took into account the total energy
expended on walking, climbing stairs, and participation in
sports or recreational activities, the duration per episode no
984 Circulation August 29, 2000

TABLE 3. Relative Risks of Coronary Heart Disease, 1988 1993, According to

Total Energy Expenditure
Relative Risk (95% CI)
Total Energy
Expenditure, Adjusted for Age and Duration
kJ/wk* Adjusted for Age per Exercise Episode Multivariate
4200 1.00 (Referent) 1.00 (Referent) 1.00 (Referent)
42008399 0.75 (0.590.97) 0.76 (0.561.03) 0.80 (0.571.12)
840012 599 0.77 (0.591.01) 0.75 (0.531.07) 0.80 (0.551.18)
12 60016 799 0.78 (0.571.08) 0.75 (0.501.14) 0.74 (0.471.17)
16 800 0.70 (0.530.91) 0.66 (0.450.98) 0.62 (0.410.96)
P, trend 0.009 0.09 0.046
*Estimated from walking, climbing stairs, and participation in sports or recreational activities.
Determined from the sport or recreational activity in the past week with the longest average
duration per episode, classified as in Table 1.
Also adjusted for cigarette smoking; hypertension; diabetes; early parental death; intake of
vitamin or mineral supplements; alcohol, red meat, and vegetable consumption; and participation in
vigorous activities (6 METs).

longer predicted coronary heart disease risk (P trend0.68;
Table 2). That is, among men who expended similar total
amounts of energy in physical activity, a longer duration per
episode of activity did not further decrease coronary heart
disease risk. Furthermore, men who engaged in sports or
recreational activities, regardless of the duration per episode,
did not experience lower risks of coronary heart disease than
did those who only walked and climbed stairs but did not
report additional participation in sports or recreational activ-
ities, provided the total energy output was similar. (Among
the 1874 men who did not report any sports or recreational
activities, all except 94 walked or climbed stairs.) With
additional adjustment for body mass index, smoking, hyper-
tension, diabetes mellitus, early parental death, vitamin or
mineral supplements, alcohol intake, diet, and participation in
vigorous activities, the duration per episode continued to
show no association with coronary heart disease risk (P
trend0.25). In a sensitivity analysis, we refined the longest
duration category by defining 2 groups: 61 to 120 and 120
minutes; this did not change the findings (P trend0.21; data
not shown).
We then analyzed the subgroup of men who reported at
least 1 sport or recreational activity. After adjustment for total
energy expenditure, as well as the potential confounders
listed earlier, the relative risks of developing coronary heart
disease associated with duration per exercise episode of 1 to
15, 16 to 30, 31 to 45, 46 to 60, and 60 minutes were 1.00
(referent), 0.88 (95% CI 0.52 to 1.48), 0.95 (0.52 to 1.74),
1.02 (0.59 to 1.75), and 1.06 (0.63 to 1.79), respectively (P
trend0.41).
In contrast, the total energy expended on physical activity
consistently predicted a decreased risk of coronary heart
disease (Table 3). Of the 482 men who developed coronary
heart disease, 182, 98, 74, 47, and 81, respectively, fell into
the 5 categories of total energy expenditure. In an age-
adjusted analysis, greater amounts of energy expended on
walking, climbing stairs, and participation in sports or recre-
ational activities strongly predicted decreased coronary heart
disease risk (P trend0.009). With additional adjustment for
duration per episode of activity, there was an inverse associ-
ation with risk that was of borderline significance (P
trend0.09). However, with further adjustment for the other
potential confounders described earlier, the inverse associa-
tion again attained significance (P trend0.046). In all
regression models, men who expended 16 800 kJ/wk in
physical activity experienced a significantly lower (on the
order of 30% to 40%) risk of coronary heart disease compared
with those expending only 4200 kJ/wk.
When we excluded the first 2 years of follow-up to
minimize potential bias resulting from men who may have
decreased their physical activity at study entry because of
symptoms from as-yet-undiagnosed heart disease, findings
were little changed (data not shown). Finally, we investigated
whether the association of the duration of an exercise episode
with coronary heart disease risk differed among subgroups of
men defined on the basis of various characteristics. We did
not observe any effect modification among men of different
ages (P0.38), among those with different levels of total
energy expenditure (P0.14), or between those who did and
those who did not engage in vigorous activities (P1.00).
Discussion
These prospective data indicate that longer durations spent on
each episode of exercise are not associated with decreased
coronary heart disease risk compared with shorter durations,
once total energy expenditure is taken into account. Stated in
another way, it appears that the accumulation of shorter
sessions of activity is associated with equivalent benefit (at
least, with regard to coronary heart disease risk) compared
with longer sessions, as long as the total amount of energy
expended is similar. Even men who only walked and climbed
stairs and did not report additional participation in sports or
recreational activities fared as well as those who engaged in
sports or recreational activities, provided their total energy
output was similar. In analyses, we chose not to adjust for the
frequency of physical activity because the combined contri-
bution of frequency and duration of exercise episodes yields
total energy expenditure. Thus, by the inclusion of terms for
duration and total energy expenditure in regression models,
the analyses have indirectly accounted for frequency.

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 Lee et al
No previous study has assessed the association of duration
of exercise episodes, apart from its contribution to total
energy expenditure, with coronary heart disease risk. Two
trials investigated the effects of short versus long sessions of
exercise on cardiovascular risk factors. Ebisu5 reported that
young men who ran 6 miles a day, whether in 1, 2, or 3
sessions, experienced similar increases in physical fitness
after 10 weeks, whereas HDL-cholesterol levels increased
most in the 3-session group.5 In another experiment, DeBusk
et al6 observed that physical fitness improved after 8 weeks
among middle-aged men who jogged 30 minutes a day,
whether in 1 or 2 sessions, although the former group had
greater improvement. Although it is unclear whether these
findings extend to more moderate-intensity activities (eg,
walking), the results from these experimental studies may
explain why we found no effect of the duration of an exercise
session on coronary heart disease risk, after accounting for
total energy expenditure.
In an observational study with data that were collected at a single
examination, Mensink et al18 found that among men and women
aged 25 to 69 years, the frequency of exercise appeared to better
predict cardiovascular risk factors compared with exercise intensity
or the total time spent exercising. However, total energy expenditure
was not held constant, so this finding may instead reflect the
association with the amount of energy expended. Recently, 2 trials
reported on changes in cardiovascular risk factors among subjects
assigned to an intervention that promoted lifestyle physical activity
(ie, use of recent physical activity recommendations) or an inter-
vention that promoted traditional exercise prescriptions.19,20 With
both interventions, small but significant increases occurred in both
physical activity and fitness. However, data regarding actual dura-
tions per episode of physical activity were not provided. Presum-
ably, subjects assigned to the former group would likely accumulate
short sessions of activity, whereas those assigned to the latter group
would likely incline toward exercising in a continuous, longer
session. After 1 to 2 years of follow-up, beneficial changes were
observed for fat mass and blood pressure levels in both intervention
groups; however, benefits for the lipid profile were less clear.
The interpretation of results from the present study must be
tempered by some potential limitations. One alternate expla-
nation for the lack of association between the duration of an
exercise episode and coronary heart disease risk might simply
be that duration was imprecisely reported, leading to misclas-
sification. Furthermore, each exercise episode reported by a
subject may not have involved continuous activity but rather
fragmented spurts. For example, men who reported playing
tennis or golf for 1 hour each episode might have taken
breaks for conversation or other reasons, as is likely in a
social, rather than competitive, context. In addition, we
determined the duration of exercise episodes on the basis of
sports and recreational activities only; we did not do so for
walking or climbing stairs. Finally, it would be useful to
examine the potential health benefits of initially sedentary
men taking up short sessions of physical activity. Unfortu-
nately, we were unable to reliably investigate this because
only 5% of men had changed from being initially sedentary
before study entry to participating in sports or recreational
activities at baseline in 1988.
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Duration of Activity and CHD Risk 985
Subjects in the present study were of a higher educational
and socioeconomic status, with the vast majority being
university graduates. However, the biologic effects of phys-
ical activity are likely to apply to the general population as
well. Physical activity lowers blood pressure levels,21 in-
creases insulin sensitivity,22 and favorably influences lipid
profiles.23,24 It also enhances cardiac mechanical and meta-
bolic function25 and improves hemostatic factors, decreasing
platelet aggregation26 and increasing fibrinolytic activity.27
These beneficial effects likely explain the decreased coronary
heart disease risk with increased physical activity.
In conclusion, these data clearly indicate that physical
activity is associated with decreased coronary heart disease
risk. Furthermore, they lend some support to current recom-
mendations that allow for the accumulation of shorter ses-
sions of physical activity, as opposed to requiring 1 longer,
continuous session of exercise. Physicians should advise
patients to be physically active to decrease their coronary
heart disease risk. Physical activity does not have to be
arduously long to be beneficial; even short sessions lasting 15
minutes appear to be helpful. This may provide some impetus
for sedentary individuals to take up physical activity.
Acknowledgments
This work was supported by research grants HL-34174 from the
National Heart, Lung, and Blood Institute and CA-44854 from the
National Cancer Institute, US Public Health Service. We are grateful
to Stacey DeCaro, Sarah E. Freeman, Tina Y. Ha, Martha J. Higgins,
Rita W. Leung, Doris C. Rosoff, and Alvin L. Wing for their help
with the College Alumni Health Study.
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