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Low physical activity as a predictor for total and cardiovascular disease mortality in middle-aged men and women in Finland

Noël C Barengo, Gang Hu, Timo A Lakka, Heikki Pekkarinen, Aulikki Nissinen, Jaakko Tuomilehto
DOI: http://dx.doi.org/10.1016/j.ehj.2004.10.009 2204-2211 First published online: 10 December 2004

Abstract

Aims To investigate separately for men and women whether moderate or high leisure time physical activity, occupational physical activity, and commuting activity are associated with a reduced cardiovascular disease (CVD) and all-cause mortality, independent of CVD risk factors and other forms of physical activity.

Methods and results Prospective follow-up of 15,853 men and 16,824 women aged 30–59 years living in eastern and south-western Finland (median follow-up time 20 years). CVD and all-cause mortality were lower (9–21%) in men and women (2–17%) who were moderately or highly physically active during leisure time. Moderate and high levels of occupational physical activity decreased CVD and all-cause mortality by 21–27% in both sexes. Women spending daily 15 min or more in walking or cycling to and from work had a reduced CVD and all-cause mortality before adjustment for occupational and leisure time physical activity. Commuting activity was not associated with CVD or all-cause mortality in men.

Conclusion Moderate and high levels of leisure time and occupational physical activity are associated with a reduced CVD and all-cause mortality among both sexes. Promoting already moderate levels of leisure time and occupational physical activity are essential to prevent premature CVD and all-cause mortality.

See page 2183 for the editorial comment on this article (doi:10.1016/j.ehj.2004.10.014)

Keywords Physical activity; Leisure time; Commuting; Occupational; Mortality; Cardiovascular

Introduction

Many epidemiological studies have shown that low physical activity is a strong and independent risk factor for both cardiovascular disease (CVD) and all-cause mortality.1–9 Further, quantitative estimates have given reason to believe that a sedentary lifestyle is responsible for approximately 30% of deaths due to coronary heart disease.10 A total of 14% of all deaths in the United States have been estimated to be attributable to physical inactivity and an unhealthy diet.11 Whereas there is convincing evidence that physical activity reduces CVD and all-cause mortality among men,2,5,8,9,12–21, only a few longitudinal studies have been conducted among women.1,22–26

Most previous studies have focused on the health effects of leisure-time physical activity alone 4,13,15,16,21,27 whereas the evidence on the associations of occupational physical activity and commuting activity with CVD and total mortality is limited and inconsistent.1,2,14,16,23,28 However, it is important to understand the separate effects of the different forms of physical activity on CVD and all-cause mortality. While some individuals could increase their physical activity in leisure time, others may gain a health benefit from being more physically active on their way to work or at work. The results of studies investigating the relations of occupational physical activity with CVD and all-cause mortality are controversial, varying from no association at all14,16,28,29 to a statistically significant relation even when controlling for various risk factors.1,22,23 Furthermore, only a few epidemiological studies have been conducted in a true population sample 5,7,12–14,19,20 or their results were adjusted for a few confounding factors only.6,12,17,21

The purpose of the present study was to investigate separately for men and women whether moderate or high leisure-time physical activity, occupational physical activity and commuting activity are associated with a reduced CVD and all-cause mortality independent of cardiovascular risk factors and other forms of physical activity.

Materials and methods

Study population

Six independent cross-sectional surveys were carried out at five-year intervals within the framework of the North Karelia Project and the FINMONICA/Finrisk studies.30 An independent random sample was drawn from the national population register for each survey. In the first two surveys (1972, 1977), separate independent random samples of 6.6% of the middle-aged population were drawn in both areas. In 1982, 1987, 1992 and 1997, the samples were stratified by sex and 10-year age categories according to the WHO MONICA protocol.31 The survey methods followed the WHO MONICA protocol and were comparable to the methods used in 1972 and 1977. The FINMONICA study is the Finnish part of the multinational MONICA project initiated by WHO in 1982. The first two surveys were conducted in two regions: the provinces of North Karelia and Kuopio both located in eastern Finland. The survey expanded to the region of Turku-Loimaa in south-western Finland in 1982 and to other regions in 1992. Subjects who participated in more than one survey were included only in their first survey cohort. The total sample included 38,138 subjects. The participation rates varied between 71% and 94% in men and between 78% and 95% in women. Informed written consent was obtained starting from the participants of the 1977 survey. At the time of the earlier survey, it was not customary in Finland to ask for a written consent, but the participants were informed about the purpose of the study both in written and oral form. Each risk factor survey has been approved by the IBR before being carried out.

Subjects who were previously diagnosed with coronary heart disease (n=777), stroke (n=253), heart failure (n=1237) or cancer (n=86) at baseline, and those who were physically inactive because of severe disease or disability at baseline (n=1150) were excluded from the study. After a further exclusion of subjects with incomplete data on physical activity (n=1106), height or weight (n=487), serum cholesterol (n=120), smoking (n=232) or blood pressure (n=13) the final sample comprised 15853 men and 16824 women.

Assessment of physical activity

Leisure-time physical activity, occupational physical activity and commuting activity were determined by a self-administered questionnaire. A detailed description of the questions for the physical activity is presented elsewhere.32–35 The questionnaire used for the assessment of physical activity has been successfully used elsewhere and it has shown a high correlation with physical fitness, as measured by maximal oxygen uptake.1,23,27,36 These questions were similar to those used and validated in the 'Seven Countries Study'.37

The time frame of the activity questionnaire was a typical week. Leisure-time physical activity was classified as follows: (i) high: participation in recreational sports (for example running, jogging, skiing, gymnastics, swimming, ball-games or heavy gardening) or in intense training or sports competitions for at least three hours a week; (ii) moderate: walking, cycling or practising some other form of light exercise (fishing, gardening and hunting) at least four hours per week; (iii) low: reading, watching TV or working in the household without much physical activity.

Occupational physical activity was classified as follows: (i) high: lots of walking and lifting at work, taking the stairs or walking uphill (for example industrial work, farm work and forestry); (ii) moderate: walking quite a lot at work without lifting or carrying heavy objects and (iii) low: mostly sedentary work without much walking (for example, working in an office).

Commuting activity was classified as follows: (i) high: more than 30 min physical exercise (walking, cycling) every day while getting to work and back home; (ii) moderate: exercising between 15 and 30 min daily on the way to work and back home and (iii) low: exercising less than 15 min daily on the way to work and back home.

Assessment of other risk factors for cardiovascular disease

Smoking habits were classified according to three categories: never smokers, ex-smokers and current smokers. Education was measured in years and the subjects were divided in following categories: (i) low, 0–6 years of schooling; (ii) middle, 7–9 years of schooling and (iii) high, more than 9 years of schooling.

Height, weight and blood pressure was measured by nurses especially trained for the survey procedures. Height was measured to the nearest 0.5 cm. Weight was measure in light clothing. Body mass index (BMI) was calculated as weight in kilograms divided by height in metres squared. Blood pressure was measured from the right arm of the subject, who was seated for five minutes before the measurement. The fifth phase of the Korotkoff's sounds was recorded as the diastolic pressure. Blood pressure was measured twice and the mean of these two measurements was used in the analyses.

After blood pressure measurement, a venous blood specimen was drawn. Serum total cholesterol was determined by using the Lieberman–Burchard method in 1972 and 1977, and an enzymatic method (CHOD-PAP, Boehringer Mannheim, Mannheim, Germany) since 1982. The enzymatic assay method gave 2.4% lower values than the Lieberman–Burchard method. The cholesterol values from 1972 and 1977 were corrected by this percentage. All samples were analysed in the same laboratory.

Outcome definition

The data were complemented by linkage to the nationwide death register of Statistics Finland according to the unique national personal identification number that every Finn has. These records covered the period from January 1970 to December 2001. The Eighth, Ninth and Tenth Revisions of the International Classification of Diseases were used for coding the causes of death. The codes used for CVD were 390–459 (I00–I99). The endpoint of the follow-up was the date of death. If the subjects were alive, the follow-up ended at the latest in December 2001.

Statistical analyses

Statistical analyses were performed with SPSS for Windows 11.5. The Cox proportional hazards model was used to estimate the association between physical activity and the risk for total and CVD mortality. Physical activity categories were included in the models as dummy and categorizing variables, and the statistical significance of different categories of physical activity was tested in the same models, with the low physical activity as reference group. The proportional hazards assumption in the Cox model was assessed with graphical methods, and with models including time-by-covariate interactions.38 In general, all proportionality assumptions were appropriate, except for the association of commuting physical activity with mortality in women. The linearity assumption of continuous variables in the Cox models was assessed by categorizing the variables (10 sex-specific categories for each continuous variable), and looking at the differences in log hazards between the categories.

All analyses were adjusted for the following covariates: age, study year, education, smoking status, systolic blood pressure, cholesterol level, BMI and two other types of physical activity. Estimated hazard ratios and their 95% confidence intervals are presented. A p-value of less than 0.05 (two-side) was considered as statistically significant.

Results

The baseline characteristics of the study population are presented in Table 1.

View this table:

Table 1. Baseline characteristics of study sample by sex

Men (n=15,853)Women (n=16,824)
a Mean (standard deviation).
Age (years)43.4 (8.4)a43.8 (8.5)
Body mass index (kg/m2)26.3 (3.6)25.9 (4.5)
Diastolic blood pressure (mm Hg)89 (12)85 (12)
Systolic blood pressure (mm Hg)143 (18)139 (22)
Serum cholesterol (mmol/l)6.3 (1.2)6.1 (1.3)
Education (years)9.1 (3.7)9.5 (3.7)
Body mass index, (%)
<2538.748.3
25–29.947.234.9
⩾3014.116.8
Smoking (%)
Never33.376.0
Ever23.07.7
Current43.716.3
Occupational activity (%)
Low29.034.3
Moderate23.835.0
High47.230.7
Walking or cycling to and from work (%)
<15 min64.354.3
15–29 min17.020.1
⩽30 min18.725.6
Leisure time physical activity (%)
Low27.636.9
Moderate52.649.9
High19.813.2

During a median follow-up of 20 years (13 and 25 years for the 25th and the 75th quartiles, respectively), 3410 men died, of whom 49% were due to CVD. Among the women, 1862 were deceased of which 42% was due to CVD (Table 2). All-cause and CVD mortality was lower in men and women who were classified as moderately or highly physically active during leisure time than among the groups with low leisure-time physical activity. The risk reduction in all-cause mortality was 9% (95% confidence interval [CI] 2–16%) among men who had moderate leisure time physical activity and 21% (95% CI 10–30%) among those who reported high leisure-time physical activity when adjusted for age, body mass index, systolic blood pressure, total cholesterol, education, smoking status and even for occupational physical activity and commuting activity. A similar picture was found regarding CVD mortality with a risk reduction of 9% (95% CI 0–18%) and 17% (95% CI 1–31%) among men with moderate and high leisure time physical activity compared with men with low levels of leisure time physical activity, respectively. A risk reduction in all-cause and CVD mortality was found in women who had moderate or high leisure-time physical activity as well. However, the relative risk of all-cause mortality varied between 0.89 (moderate leisure time physical activity, 95% CI 0.81–0.98) and 0.98 (high leisure time physical activity; 95% CI 0.83–1.16) compared to women who were inactive in their leisure time.

View this table:

Table 2. Hazard ratios for total and cardiovascular mortality according to different levels of leisure time physical activity, with various forms of adjustmenta

Leisure time physical activityNo. of subjectsNo. of deathsPerson-yearAdjusted hazards ratios (95% confidence intervals)
ABC
a A, adjusted for age and study year; B, adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, and smoking status; C, adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, smoking status, and other physical activity.
All-cause mortality
Men
Low4372118481,0281.001.001.00
Moderate83371853153,3840.85 (0.79–0.92)0.91 (0.85–0.98)0.91 (0.84–0.98)
High314437357,0630.60 (0.53–0.68)0.80 (0.71–0.90)0.79 (0.70–0.90)


Women
Low6212907130,4611.001.001.00
Moderate8387783156,4690.85 (0.77–0.94)0.90 (0.82–0.99)0.89 (0.81–0.98)
High222517240,4590.87 (0.74–1.02)0.98 (0.83–1.15)0.98 (0.83–1.16)


Cardiovascular mortality
Men
Low437259081,0281.001.001.00
Moderate8337901153,3840.84 (0.76–0.93)0.90 (0.82–0.99)0.91 (0.82–1.00)
High314417057,0630.58 (0.49–0.69)0.83 (0.70–0.99)0.83 (0.69–0.99)


Women
Low6212417130,4611.001.001.00
Moderate8387303156,4690.75 (0.65–0.87)0.83 (0.72–0.97)0.83 (0.71–0.96)
High22255840,4590.71 (0.54–0.93)0.89 (0.67–1.17)0.89 (0.68–1.18)

Women who were moderately or highly active during leisure time had lower CVD mortality (HR 0.83; 95% CI 0.71–0.96 and 0.89; 95% CI 0.68–1.18, respectively) than those with low leisure time physical activity when adjusted for age and year of survey, BMI, systolic blood pressure, total serum cholesterol, education, smoking, and also for commuting activity and occupational physical activity.

Table 3 presents the risks of CVD and all-cause mortality among groups with different levels of occupational physical activity separately for men and women. Moderate and high occupational activity decreased CVD and all-cause mortality significantly compared with people with low occupational physical activity in both men and women. When adjusted for age and survey year, education, smoking, total cholesterol, systolic blood pressure, body mass index as well as commuting and leisure-time physical activity, the hazard ratio did not change remarkably and remained statistically significant. The risk reduction in men regarding all-cause mortality was 25% (95% CI 17–32%) for moderate occupational physical activity and 23% (95% CI 16–29%) for high occupational physical activity. Women with moderate occupational physical activity showed a 21% risk reduction in all-cause mortality (95% CI 11–30%) and those with high occupational physical activity a 22% risk reduction (95% CI 13–30%). The risk reduction in CVD mortality varied among men between 24% (high occupational physical activity) and 25% (moderate occupational physical activity) and among women between 23% (high occupational physical activity) and 27% (moderate occupational physical activity) compared with subjects who are physically inactive at work.

View this table:

Table 3. Hazard ratios for total and cardiovascular mortality according to different levels of occupational physical activity, with various forms of adjustmenta

Occupational physical activityNo. of subjectsNo. of deathsPerson-yearAdjusted hazards ratios (95% confidence intervals)
ABC
a A, adjusted for age and study year; B, adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, and smoking status; C, adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, smoking status, and other two physical activity.
All-cause mortality
Men
Light4601104275,2351.001.001.00
Moderate377762572,0320.69 (0.62–0.76)0.75 (0.68–0.83)0.75 (0.68–0.83)
Active74751743144,2090.83 (0.77–0.90)0.79 (0.73–0.86)0.77 (0.71–0.84)


Women
Light5770695103,1211.001.001.00
Moderate5895533117,0990.74 (0.66–0.83)0.78 (0.69–0.87)0.79 (0.70–0.89)
Active5159634107,1690.78 (0.70–0.87)0.78 (0.70–0.88)0.78 (0.70–0.87)


Cardiovascular mortality
Men
Light460151275,2351.001.001.00
Moderate377729172,0320.65 (0.57–0.76)0.75 (0.65–0.87)0.75 (0.64–0.87)
Active7475858144,2090.82 (0.74–0.92)0.79 (0.71–0.89)0.77 (0.69–0.87)


Women
Light5770302103,1211.001.001.00
Moderate5895192117,0990.63 (0.53–0.76)0.70 (0.59–0.85)0.73 (0.60–0.88)
Active5159284107,1690.78 (0.66–0.92)0.77 (0.66–0.92)0.77 (0.65–0.91)

Women spending daily 15 min or more in walking or cycling to and from work had a significantly reduced CVD and all-cause mortality than women who had low levels of commuting activity (Table 4). The risk reduction remained significant when controlling for body mass index, systolic blood pressure, serum cholesterol, smoking, and education. However, after additional adjustment for occupational physical activity and leisure time physical activity, the association was no longer statistically significant. No effect of commuting activity on CVD or all-cause mortality was found in men.

View this table:

Table 4. Hazard ratios for total and cardiovascular mortality according to different levels of walking or cycling to and from work, with various forms of adjustmenta

Walking or cycling to and from workNo. of subjectsNo. of deathsPerson-yearAdjusted hazards ratios (95% confidence intervals)
ABC
a A, adjusted for age and study year; B, adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, and smoking status; C, adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, smoking status, and other two physical activity.
All-cause mortality
Men
<15 min10,1881948177,9871.001.001.00
15–29 min270258653,1450.91 (0.83–1.00)0.96 (0.88–1.06)1.01 (0.92–1.11)
⩾30 min296387660,3430.98 (0.90–1.06)1.00 (0.92–1.09)1.07 (0.98–1.17)


Women
<15 min91411081173,6091.001.001.00
15–29 min338729866,8530.83 (0.73–0.95)0.85 (0.75–0.97)0.89 (0.78–1.02)
⩾30 min429648386,9270.89 (0.80–0.99)0.93 (0.84–1.04)0.98 (0.88–1.09)


Cardiovascular mortality
Men
<15 min10,188937177,9871.001.001.00
15–29 min270229953,1450.94 (0.83–1.08)1.03 (0.90–1.17)1.08 (0.95–1.23)
⩾30 min296342560,3430.93 (0.83–1.04)0.98 (0.87–1.10)1.05 (0.93–1.19)


Women
<15 min9141480173,6091.001.001.00
15–29 min338710266,8530.68 (0.55–0.84)0.73 (0.59–0.90)0.78 (0.62–0.97)
⩾30 min429619686,9270.82 (0.69–0.96)0.91 (0.77–1.08)0.97 (0.82–1.15)

Additional analyses were conducted including subjects who were physically inactive because of severe disease or disability at baseline. The protective effect of leisure-time and occupational physical activity became a little bit stronger (risk reduction increased by 1–2%) than it was after excluding these subjects (data not shown).

The joint associations of different forms of physical activity on the risk of CVD and all-cause mortality are presented in Figs. 1–4. We dichotomized all three types of physical activity as light versus moderate to high levels for leisure-time and occupational physical activity, and at a threshold of 15 min for commuting physical activity. All subjects were classified into eight categories according to the three types of physical activity: subjects who reported low levels of occupational, commuting and leisure-time physical activity were used as the reference group. There was a statistical significant risk reduction in CVD mortality among women in all joint association forms of physical activity compared to the references category. In men, a significant risk reduction of CVD mortality was mainly found among those who had moderate or high occupational physical activity (Fig. 1 and 2). Active men and women who engaged in only one form of physical activity had a statistically significant lower all-cause mortality compared to the reference category (Figs. 3 and 4).

Fig. 1

Hazard ratios of CVD mortality according to commuting activity, leisure-time and occupational physical activity among men. Adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, and smoking status.

Fig. 2

Hazard ratios of CVD mortality according to commuting activity, leisure-time and occupational physical activity among women. Adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, and smoking status.

Fig. 3

Hazard ratios of all-cause mortality according to commuting activity, leisure-time and occupational physical activity among men. Adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, and smoking status.

Fig. 4

Hazard ratios of all-cause mortality according to commuting activity, leisure-time and occupational physical activity among women. Adjusted for age, study year, body mass index, systolic blood pressure, cholesterol, education, and smoking status.

Discussion

To our knowledge, this is the first study which has analysed separately the relationship between different forms of daily physical activity and CVD and all-cause mortality in a large population cohort including both middle-aged men and women. Our results show that already moderate and high levels of leisure time physical activity and occupational physical activity were associated with a reduced risk of CVD and all-cause mortality among both sexes. The relation remained significant even after adjusting for the most common risk factors for CVD and for other forms of physical activity. Commuting activity seemed to be inversely associated with CVD and all-cause mortality among women, although the risk reduction was not statistically significant.

Physical activity acts through many metabolic and other pathways which affect cardiovascular risk factors. It improves plasma lipid profile, reduces body weight, lowers blood pressure, reduces platelet aggregation, increases fibrinolytic activity, improves cardiac function, improves cardio-respiratory fitness and lowers the resting heart rate. Furthermore, exercise training seems to improve endothelium-dependent vasodilatation 39,40 and to increase urinary sodium excretion and insulin sensitivity.41 In addition, it has been reported that physical activity affects the immune system by increasing natural killer cells and by enhancing their cancer inhibitory abilities.42 Long-term exercise may be associated with a decrease of atherogenic activity of blood mononuclear cells and with lower C-reactive protein levels.43, 44 Clinical experiments have also given a reason to believe that physical activity elevates levels of enzymes which act as scavengers against cancer-causing free radicals.45 In the end, physical activity positively affects the psychosocial well being of the individual.2 Interestingly, the mortality differences by physical activity found in individual-based analyses could not be explained by genetic factors.4

Most previous studies have found an inverse association of physical activity with CVD and all-cause mortality among men.2,4,6–9,12,13,15,17,18,20 Furthermore, several meta-analyses have supported an effect of physical activity on longevity as well.46,47,48 Surprisingly, only a few studies on physical activity have been conducted among women. Most of them have reported health beneficial effects of all levels of leisure time physical activity on CVD or all-cause mortality.1,22,24,27,49 Two studies could not show an association between leisure time physical activity and longevity. 25,26 However, both studies were lacking statistical power to observe a possible effect due to their small samples sizes and too few outcome events. Our results indicate that leisure time physical activity is inversely associated with CVD and all-cause mortality rates not only in men but also in women.

The findings regarding health benefit and occupational physical activity are controversial. In this general population, we found a reduced risk of CVD and all-cause mortality among both men and women for moderate levels of occupational physical activity already. We also found that moderate or higher levels of occupational physical activity reduced total and CVD mortality among patients with type 2 diabetes.35 The results of Salonen and co-workers 23,49 are in line with ours. This study was carried out earlier among the population in Eastern Finland where a part of our study was also conducted, but it comprised older birth cohorts. Other studies do not support these findings.14,16,28,29 However, these studies did not adjust for most common cardiovascular risk factors, leisure time physical activity or commuting activity.28,29 Thus, their results may be confounded by leisure time physical activity because people with low occupational physical activity tend to be more active at leisure-time than those with high occupational physical activity as shown in our study material in a previous report.50 The few previous studies conducted among women support our observation that occupational physical activity is inversely associated with CVD and all-cause mortality.22,23,49 Only one study has investigated the association between occupational physical activity and the risk of all-cause mortality adjusting for leisure time physical activity and commuting activity.1 They found an inverse relation between occupational physical activity and all-cause mortality among women, but not among men.

There is evidence that regular walking is associated with a reduced incidence of cardiovascular events.51 However, studies investigating the effect of commuting activity on mortality rates are very scarce. We found only one study, which documented a 28% decrease in mortality rates for people bicycling to work.1 Even though their results were adjusted for multiple risk factors, they did not include occupational physical activity. Moreover, the results were statistically significant only for men and commuting activity included only bicycling and not for instance walking to and from work. In our study, a significant reduction in CVD or all-cause mortality was found in women with daily commuting activity more than 15 min, and the association remained statistically significant until we included occupational physical activity and leisure time physical activity into the model. Previously, we have shown that daily commuting activity of 30 min or more is independently related to a reduced risk of type 2 diabetes in the present cohort.32 Thus, it is therefore possible that some of the effect of commuting activity is mediated through the reduced risk of diabetes.

One of the main strengths of our study was that our analyses were conducted among large, representative population samples of middle-aged men and women. The participation rates were high and the follow-up period was relatively long, which makes it possible to apply the results directly to the general population. Furthermore, this is to our knowledge the first study to analyse separately the associations of different forms of physical activity with mortality from CVD and all-cause. In addition, we were able to adjust our results for the most important risk factors of CVD and all-cause mortality.

Naturally, our study had some limitations. Physical activity and other predictors of mortality were assessed only at the beginning of the follow-up only, as usual in observational studies of this size. Thus, possible individual changes in the level of physical activity and other predictors of disease and mortality during the follow-up may have influenced the results. We also would like to point out that our approach was qualitative, because we divided physical activity into categories and provided a ranking, but not information about the quantitative intensity or optimal doses of activity. Quantitative measurement of physical activities is more difficult and time consuming in large population studies.

In conclusion, our results show that already moderate levels of leisure time physical activity and occupational physical activity are associated with a reduced CVD and all-cause mortality among both men and women. This protective effect was observed regardless of body mass index, age, education, smoking, total cholesterol, systolic blood pressure and other forms of physical activity. Therefore, promoting already moderate levels of leisure time physical activity and occupational physical activity is an essential component in the prevention of premature CVD and all-cause mortality.

Acknowledgments

This study was supported by a grant of the Finnish Cultural fund, the Aarne ja Aili Turunen fund, and the Finnish Academy (Grants 46558, 204274 and 205657). T.A.L. was a Research Fellow of the Academy of Finland.

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View Abstract